Kamau-A Study of the Performance of Male Nurses As Care Givers In

UNIVERSITY OF NAIROBI

FACULTY OF ARTS

DEPARTMENT OF SOCIOLOGY AND SOCIAL WORK

A STUDY OF THE PERFORMANCE OF MALE NURSES AS CARE GIVERS IN SELECTED PUBLIC HEALTH CARE FACILITIES IN KIAMBU COUNTY

WALTER THUKU KAMAU

C50/80083/2012

A PROJECT PAPER SUBMITTED TO THE DEPARTMENT OF SOCIOLOGY AND SOCIAL WORK IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS IN SOCIOLOGY (RURAL SOCIOLOGY AND COMMUNITY DEVELOPMENT), UNIVERSITY OF NAIROBI

2016

DECLARATION

STUDENTS DECLARATION

I declare that this research project is my original work and has not been submitted to any other university for an academic credit.

Signature: ______

WALTER THUKU KAMAU

Date : ______

APPROVAL BY SUPERVISOR

This research project has been submitted with my approval as the university supervisor.

Signature: ______

PROFESSOR P. CHITERE

Date : ______

DEDICATION

I dedicate this work to my family, the source of my strength.

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ACKNOWLEDGEMENTS I thank God for good health and seeing me through this journey. My unlimited thanks go to my parents, Mr. and Mrs. John Kamau Kimathi, who provided continuous encouragement, support and funding for this dissertation. I also thank my wife, Esther Watiri and my son, Jabali Kamau, who were the source of my inspiration for this study.

I would also like to thank Dr. Stephen Njuguna, Chief Officer -Health, County Government of Kiambu for easing access to the County Health Facilities. Extended thanks go to Mr. Justin N. Ngugi, Karuri Hospital for your valued assistance. I am also grateful to the staff and management of all the five health facilities for their support. My extended gratitude also goes to all the male nurses and their supervisors, coordinators who contributed to the success of this research.

Special thanks to my supervisor at the University of Nairobi, Professor Preston Chitere for his guidance, support and patience with the project and its perfection. His mentorship made it possible for me to successfully accomplish this task.

TABLE OF CONTENTS Declaration ...... ii Dedication ...... iii Acknowledgements ...... iv List of Figures ...... viii List of Tables ...... ix List of Abbreviations ...... x Definition of Terms ...... xi Abstract ...... xii

CHAPTER ONE: INTRODUCTION ...... 1 1.1 Background ...... 1 1.2 Problem Statement ...... 3 1.3 Research Questions ...... 5 1.4 Objectives of the Study ...... 5 1.4.1 Main Objective ...... 5 1.4.2 Specific Objectives ...... 5 1.5 Justification of the Study ...... 6 1.6 Scope and Limitations of the Study ...... 6

CHAPTER TWO: LITERATURE REVIEW AND THEORETICAL FRAMEWORK . 7 2.1 Introduction ...... 7 2.1.1 The History of Nursing ...... 7 2.1.2 Men in Female-Dominated Positions ...... 10 2.2 Theoretical Framework ...... 14 2.3 Conceptual Framework ...... 19 2.4 Operational Definitions ...... 21

CHAPTER THREE: RESEARCH METHODOLOGY...... 26 3.1 Introduction ...... 26 3.2 Site Description ...... 26 3.3 Research Design ...... 31 3.4 Units of Analysis and Observation ...... 32 3.5 Sampling ...... 32

3.6 Data Collection and analysis ...... 33 3.6.1 Type of Data ...... 33 3.6.2 Data Analysis Methods and Presentation ...... 33 3.7 Ethical Issues ...... 34

CHAPTER FOUR: DATA ANALYSIS, PRESENTATION AND INTERPRETATION ...... 35 4.1 Introduction ...... 35 4.2 Characteristics of the male nurses ...... 35 4.2.1. Age Distribution ...... 35 4.2.2 Marital status ...... 36 4.2.3 Education level ...... 36 4.2.4 Years of Experience as a Nurse ...... 37 4.3 Motivation for entry into nursing ...... 38 4.3 Rewards...... 46 4.4 Male nurses’ perception of their profession ...... 50 4.5 Performance ...... 59 4.6 Coping mechanisms ...... 71 4.7 Conclusion ...... 78

CHAPTER FIVE: SUMMARY, CONCLUSIONS AND RECOMMENDATIONS ...... 79 5.1 Introduction ...... 79 5.2 Summary ...... 79 5.2.1 Motivations for entry into the career ...... 83 5.2.2 Rewards...... 84 5.2.3 Male nurse's Perceptions of their career ...... 79 5.2.4 Performance ...... 79 5.2.5 Coping Mechanisms ...... 83 5.3 Conclusions ...... 843 5.4 Recommendations ...... 84

References ...... 86

LIST OF APPENDICES ...... 93 APPENDIX A: Participant Information Form ...... 93 APPENDIX B: Consent Form ...... 95 APPENDIX C: Research Instrument ...... 97 APPENDIX D: Interview Guide for Key informants ...... 106

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List of Figures Figure 1: Graphic representation of the conceptual framework...... 21

Figure 2: Map of Kenya showing specific study area highlighted in red...... 27

Figure 3: Map of administrative areas of Kiambu County...... 28

Figure 4:Respondent's age...... 35

Figure 5: Marital status...... 36

Figure 6: Level of education...... 37

Figure 7: Attitude of Parent(s)...... 44

Figure 8: Whether the attitude of parent(s) had an impact on the respondents...... 45

Figure 9: Responds' gross monthly salary...... 48

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List of Tables Table 1: Number of male nurses sampled...... 32

Table 2: Respondents' years of experience...... 37

Table 3: Factor(s) which motivated the respondents to venture into...... 38

Table 4: How the respondents joined nursing...... 42

Table 5: When respondents decided to venture into nursing...... 42

Table 6: Prior information on opportunities in nursing...... 44

Table 7: Whether the respondents character fit in with the care giving role...... 47

Table 8: Respondents who had received a promotion...... 48

Table 9: Respondents rating their work conditions...... 49

Table 10: Respondents perception of their profession...... 51

Table 11: Role perceived as feminine...... 54

Table 12: Role perceived as an 'easy job'...... 55

Table 13: Respondent perceived as a womaniser...... 55

Table 14: Men have an advantage compared to female nurse...... 57

Table 15: Female nurses have an advantage compared to male nurses...... 58

Table 16: Work Habits and Job Efficiency Ratings...... 59

Table 17: Whether respondents had any other duties around the hospital...... 63

Table 18: Respondents subject to work related disciplinary action...... 65

Table 19: Have you had any formal complaints from patients as a result of your work? ...... 66

Table 20: How the respondents rate their performance reviews...... 66

Table 21: Whether respondents agreed with their performance reviews...... 67

Table 22: Respondents evaluation of their abilities...... 68

Table 23: Respondents with awards...... 70

Table 24: Coping mechanisms of male nurses...... 71

List of Abbreviations

ECOSOC - United Nations Economic and Social Council

ILO - International Labour Organisation

KIHBS - Kenya Integrated Household Budget Survey

MTTI - Machakos Technical Training Institute

WHO - World Health Organisation

KNWR - Kenya Nursing Workforce Report

KSARAM -Kenya Service Availability and Readiness Assessment Mapping Report

MCH - Mother and child Health Clinic

NCK -Nursing Council Of Kenya

ACAS - The UK's Advisory, Conciliation and Arbitration Service

PCEA - Presbyterian Church of East Africa.

MRI- Magnetic Resonance Imaging

Definition of Terms a) Locum- Loosely translated from Latin, means “to hold a place.” Temporary nursing assignments e.g. Works in the place of the regular nurse when that nurse is absent, or when a hospital is short-staffed etc.

b) Bedside nursing- Direct patient care by taking care of the basic physiology needs e.g. feeding, toileting etc.

c) Stereotype threat - The expectation(s) that one will be judged or perceived on the basis of a social identity group membership rather than actual job performance and potential.

d) Daktari -The Kiswahili translation for doctor.

e) Triage -The process of assigning degrees of urgency to wounds or illnesses to decide the order of treatment of a large number of patients or casualties.

f) Sex refers to the biological characteristics distinguishing male and female. This emphasis male and female differences in anatomy, hormones, reproductive systems, and other physiological Features (Lindsey, 2005).

g) Gender is defined as the social, cultural, and psychological characteristics associated with masculine and feminine variables (Oakley, 1985).

h) Gender role is defined as the expected behavior associated with the status of either a male or female. Therefore, these are the expected attitudes and conduct that a society associates with each sex. This definition places gender directly in the socio-cultural perspective. (Lindsey, 2005)

i) Masculinity is defined as the possession of the qualities traditionally associated with men (Oxford English Dictionary, 2013)

j) Feminine (deduced from the definition of masculine) can be inferred to mean the possession of the qualities traditionally associated with women.

k) Tokens refers to people identified by their ascribed traits such as sex, race, religious affiliation, ethnic group, age, etc. that carry with them a set of high assumptions about their status and behavior which are highly outstanding from the majority of the population (Kanter, 1977).

ABSTRACT The study analysed male nurses as care givers to document their performance in a profession perceived to demand qualities traditionally associated with women. The analysis of gender and its impact has predominantly focused on the experiences of women working in male-dominated fields. There is very limited research, in Kenya, conducted to explore the experiences of men working in female-dominated professions. This study, therefore, examined the role of male nurses as care givers by analysing their performance in selected public health care facilities in Kiambu County.

Quantitative and qualitative data were obtained from a sample of 48 male nurses, present in the selected research sub-sites during the research period. The areas of focus were on their motivations for entry into the careers, the rewards the male nurses considered most important, the male nurses' perceptions of their careers, self-evaluation of their performance and the coping mechanisms they employed to deal with the female-dominated work environment. Additional qualitative data was further obtained through interviews with 5 purposively selected key informants.

The study found that most of the respondents were confident in their abilities to comfortably execute their duties. However, a number indicated they were either average and/or needed improvement in some areas such as communication skills, organisation and planning skills, and ability to handle complex health situations. This indicated a need for further training or retraining to build confidence and refresh the knowledge of the particular respondents. About 2.1% of the respondents reported having been subject to disciplinary action while a similar percentage were subject to a formal complaint from a patient. It was, none the less, important to note that 97.9% of the respondents had no disciplinary cases and /or formal complaints which painted a picture of a mostly effective and disciplined male workforce. On an even more positive note, 18.8% of the respondents had either been nominated for or were recipients of an award(s) due to their exemplary job performance.

The study found there was need for: (i) reviewing of the enrollment policies for colleges and universities to increase the number of young men in nursing; (ii) development of policies that introduce gender mainstreaming to the nursing profession; (iii) development of programs that target boys in their early ages to introduce them to nursing; (iv) establishment of male-only awards as a means to highlight their performance; (v) there is need to conduct more research on the experiences of men working in female-dominated professions and the different psychological aspects of how the men deal with the predominantly female working environments; (vi) conducting research on the history men of nursing in Kenya; (vii) conducting research on the claims that some of the nurses were resorting to substance abuse as a way of dealing with the stress and/or due to the ease of accessibility.

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CHAPTER ONE: INTRODUCTION

1.1 Background According to Article 43(a) of the Constitution of Kenya, under economic and social rights of citizens, every person has the right to the highest attainable standard of health, which includes the right to health care services, including reproductive health care. The establishment of this provision of health services as a human right, therefore, obligates the national government, county governments and other stake holders to formulate and implement policies that ensure that this constitutional provision is met.

However, Kenya’s health sector human resource insufficiency is well documented (Wakaba et al., 2014). This has made it difficult to meet the crucial responsibility of providing proper health care to every citizen in Kenya. The shortage is not unique to Kenya since it is experienced on a global scale. It is estimated that the world will be short of 12.9 million health-care workers by 2035, a figure that is currently estimated stands at about 7.2 million (W.H.O, 2013). The problem of plugging this deficit is not borne by Kenya alone, but it is a global crisis. The report further says that it is in sub-Saharan Africa where the shortages will be especially acute. On education and training, for example, in the 47 countries of sub-Saharan Africa, just 168 medical schools exist. Out of those countries, 11 have no medical schools, and 24 countries have only one medical school.

An analysis of statistics of the health workers in Kenya demonstrates that the bulk of health care services are provided by nurses (Kiambati, Kiio and Toweett, 2013). The health care profession is one of few fields in Kenya where one has a very high likelihood of securing employment upon successful completion of training. Singer (2005), Kenyan nurses in brain-drain, writes that

"Kenya is facing a nursing shortage of up to 50 per cent...... the Ministry of Health's nursing division estimates that Kenya has about 17,000 public-sector nurses, but requires 35,000."

According to the WHO (2013) report there are fewer young people (more so young men) interested in venturing into the profession which is baffling considering the high demand for nurses.

According to the Kenya Nursing Workforce Report (2012, pg.43), the public sector health facilities have employed 23% male nurses, 17% in Faith-based health facilities and 18% in Parastatal health care facilities. Men are evidently a minority in the nursing labour market. Wakaba et al. (2014), estimates that, of the 16,371 nurses in the public non-tertiary sector, 76% are women. Since female nurses comprise the majority and yet the shortage persists, men become the logical source for more labour and employees (Smith, 2008). At 24%, male nurses are a minority, coupled with the shortage in the field, more needs to be done to encourage more men to venture into nursing as a means to address this shortage as well as possibly establish a gender balance in the profession.

This study focused on the few men who identified the field and ventured into nursing as a career. The aim of the analysis, of the performance of these male nurses, was to provide insight and knowledge on possible ways of inspiring more men to venture into nursing.

The Kenya Integrated Household Budget Survey (KIHBS, 2005/06), estimates that the unemployment rate stands at 40% of the labour force, out of which 67% is youth. According to ILO, quoted in Schoof (2006), out of every five unemployed Kenyans, three fall in the 18-35 years age bracket. This is a clear indication that unemployment in Kenya is a major problem especially for the youth in the population. Diversifying the labour markets especially the gendered professions may provide an avenue for addressing unemployment.

Therefore, there is a need to build knowledge and draw lessons on ways to encourage more young men to venture into female-dominated careers, such as is nursing, and in the process address the shortage of nurses in Kenya and provide a possible solution to youth unemployment in Kenya.

1.2 Problem Statement The study focused on men working in what has culturally and traditionally been labeled as a woman’s profession. Williams (1995), as cited in Warmimg (2005), argues that when a man makes a career choice for a field regarded as feminine, this is deemed as a devaluation of status. Male-associated qualifications are perceived to have a higher status and prestige attached to them. Nursing is a professional category which has traditionally been women-oriented in Kenya (Kiambati et al., 2013). The study focused on the few men who have dared to challenge gender limits and traditional gender structures. The men who have redefined the traditional perception of masculinity and cleared the way for other men to venture into fields long regarded as feminine (Warming, 2005).

Kimmel and Messner (1992) point out that rarely are men understood through the prism of gender. Therefore, the focus on male nurses provides a fresh analysis of gender relations based on men being in the minority positions as opposed to the prevalent analysis of women in male- dominated professions. There has been little focus on men who have ventured beyond the traditional gender limits and ventured into what has been labeled as feminine roles.

The gender analysis is skewed in favour of women. The literature on the challenges faced by women who have ‘crossed over’ into male-dominated professions is numerous. Madegwa (20 11) conducted a study on the challenges of career development faced by women in senior management positions in the civil service in Kenya. Irura (1999) conducted a study on the career mobility among women administrators in Kenyan universities. Mutuku (2011) conducted a study that assessed the women workers' rights in employment as a quest for equal opportunity. Meso (2011) conducted a study on the tactics adopted by female managers in Kenya’s energy sector to deal with unique challenges they face due to their gender. Kalii (1997) conducted a study that sought to determine the factors perceived by bank executives as hindering the career progress of women in commercial banks and also sought to determine the executive’s attitudes towards female managers.

There is little analysis, here in Kenya, on men who have ventured into feminine perceived roles and/or professions as opposed to some countries specifically in the West. Similar studies have been conducted in other countries such as in the United States of America by Smith (2008), in the

United Kingdom by Simpson (2004) and in Denmark by Warming (2005). There is little or no research on men who have taken up nontraditional occupations and are a labour minority in Kenya. Fragments of information analysing masculinity can be traced in several researches such as Mbuki (2012) who conducted a study whose main research questions explored the extent to which patriarchy system, masculinity, socio-culture and gender stereotyping influences participation of men in self-help groups and Elijah, Kimani and Wango (2014) who conducted a study aimed at exploring gender-related challenges faced by students (both male and female) in learning technical courses in Machakos Technical Training Institute (MTTI). There is however, no tangible research in Kenya on the men in a gendered labour market. Mills and Lingard (1997) rightly point out that gender discussions are carried out as though they pertain only to women which inevitably has perpetuated a sort of cultural fiction that men are not gendered. There is, therefore, a tendency to overlook issues concerning men in ‘female’ roles, which possibly reflects gender studies dominating focus on women (Simpson, 2004). The stereotypes associated with men who are in nontraditional occupations poses a challenge to inspiring more men to venture into such fields as nursing. There is little research in the field hence there is a gap in identifying what are limitations for being a man in certain professions.

Hesse-Biber and Carter (2005) argue that the increase of men in an occupation, subsequently leads to an increase of wages for both genders and stereotypes associated with these careers are also altered. Therefore, research into the field with a view of encouraging more men to join these feminine professions may be of benefit across the board.

The gendered labour market analysis from the perspective of men as minorities has yet to be pursued in depth in Kenya. This means that little is known about the challenges and experiences of men in female-dominated occupations and the coping mechanism these men have developed. The aim of the paper was to address that research gap.

1.3 Research Questions i. What are the motivations for entry into a career in nursing for men? ii. What are the rewards for men in nursing? iii. What are the perceptions of the male nurses in regards to their profession? iv. How do male nurses perfom as caregivers? v. What coping mechanisms have the male nurses adopted in dealing with a female- dominated work environment?

1.4 Objectives of the Study

1.4.1 Main Objective The main objective of this study was to examine the performance of male nurses in a profession that is perceived to demand qualities that are traditionally associated with women for the purpose of generating information that would be helpful in designing policies and/or campaigns aimed at encouraging more men to venture into nursing, and possibly, other female-dominated professions as well.

1.4.2 Specific Objectives The specific research objectives of this study are:

i. To establish the motivations for entry into nursing as a career, which is a non-traditional occupation for men. ii. To identify the rewards for men in nursing. iii. To establish the male nurses’ perception of their profession. iv. To analyse the performance of male nurses as caregivers. v. To establish the coping mechanisms employed by male nurses as they work in a female- dominated profession.

1.5 Justification of the Study Examining the performance of male nurses in a female-dominated profession gives a unique understanding in regards to gender relations from the perspective of men as minorities. The knowledge generated will be distinct since the gender analysis has been traditionally (or mostly) carried out with the underlying objective of empowering women. This study sought to borrow a leaf from the traditional gender analysis with an underlying objective of empowering men who would wish to venture into female-dominated careers.

The nursing profession has a systemic bias since it is perceived to demand traits that are traditionally associated with women. This study aimed at dispelling that assumption by generating information that may be insightful by examining the performance of male nurses despite these socially constructed gender barriers.

The information generated by the study will be helpful in designing policies, and/or may be employed in endeavors aimed at encouraging more men to venture into nursing, and possibly, other female-dominated professions as well. The increase of men’s enrollment into nursing is a promising strategy for addressing the shortage of nurses in Kenya and also provides an avenue for channeling the many young men who form part of the unemployed majority.

1.6 Scope and Limitations of the Study The study analysed the experiences of men working in female-dominated positions by focusing on male nurses. This meant that the study disregarded the fact that there were men working in other female-dominated professions such as nursery school teachers, hairdressers, librarians, the hospitality and catering industry etc. who could have also provide insightful and extensive information for the study. This study is also restricted to the selected health facilities in Kiambu County however, due to limited funds, human resources and time an extensive study focusing more health facilities in different Counties could not be carried out.

Although this study focused mainly on the influence of gender on the performance of the male nurses, it was important to note that there were other variables that impact on an individual's performance which were not looked at in this study. The variables are e.g. religious background, level of education, race and ethnic background etc.

CHAPTER TWO: LITERATURE REVIEW AND THEORETICAL FRAMEWORK

2.1 Introduction This section reviewed existing literature on men who have ventured into female-dominated careers specifically the history of nursing here in Kenya and globally as well, the findings from other researchers who have conducted similar studies in other countries on men in female- dominated professions. This section also describes the theoretical framework and its relevance to this study, as well as, also outline the assumptions that guided the study.

2.1.1 The History of Nursing Care giving, historically, falls in the domain of women and nursing, and more than any other quality it captures the process and area of the nursing profession (MacDougall, 1997). Since the era of Florence Nightingale, the icon of modern professional nursing, there has been an intrinsic link between nursing and femininity (Shula, 2000). This was referred to as the ‘The Nightingale Factor’ by Anthony (2006).

In the mid-1800s, Nightingale’s accomplishments in the Crimean War, combined with her social prominence and political influence, coalesced with changing perceptions of gender roles in Victorian England to establish the foundation of the myth of the feminine nurse, in which it was natural for women to be nurses, and conversely, unnatural for men (Anthony, 2006, pg.45)

The beginning of the 20th century marked the introduction of Western medicine in Kenya by European missionaries. They built hospitals and embarked on educating the local communities about diseases. The first hospital was built in 1903 in Weithaga and later in 1908 Maseno Hospital was built (Ndirangu, 1982, pg.19-22).

At the time, getting local people to train in nursing (or dressing, as it was referred to at the time) was difficult since Western medicine was perceived to be infringing on local customs, beliefs and practices. This fueled fear among the local community members of being ostracised by other

community members for their involvement. In 1908, the first local was trained as a dresser or nurse and gradually, afterwards, the number of trained local dressers increased. Due to the cultural limitations women were not allowed to go for the training, so the first local people trained as dressers were men. The training covered subjects such as hygiene, sanitation, dressing of wounds, taking temperatures, and assisting during operations (Ndirangu, 1982, pg.19-21).

After a historical analysis of nursing in Kenya, it is logical to assume that initially, early 20th century, the nursing profession was male-dominated however, that has gradually changed over time since as it stands today men are the minority.

The training of nurses using the Kenya Registered Nursing Course was initiated in 1952 with four candidates out of which, only one was African (Mule, 1986). The first Kenyan Registered Nurse qualified in 1958. In 1960, the Kenyan Registered Nursing students who qualified were six, three African men, three women one of whom was of Goan descent. There was gender balance of the work force at the time.

Globally, the restrictions for men to work as nurses were established during the Nightingale era. Men were the medics and women were the caregivers. Women were synonymous with the care giving role because it was part of their assumed nature of compassion and care. Men, for example, were excluded from being nurses in the United States military until 1955 (Smith, 2008; LaRocco, 2007).

In some European countries up until the 1950s, there were no male nurses since the formal entrance requirement for training, as a nurse, was that the applicant should be a woman. The policy was changed in the post-war period to address the massive shortages in the field at the time (Warming, 2005).

”Like the attitude generally is in this country, as far as I can judge, nursing must be described as decidedly women’s work. […] Within nursing, the presence of special womanly characteristics is especially valuable. These are genuine empathy with and almost motherly care for their fellow human beings and a feeling for the homely touch and cleanliness, and it is also worth pointing out that the indescribable but genuinely special spirit and tone that only women can create and with which they influence their surroundings can play a special role. It should also be emphasised in this connection that when a child is ill, it is looked after by its mother and not its father.” (Denmark’s Ministry of the Interior 1949, as quoted in Warming, 2005, pg10)

This represents the sort of gendered view towards the nursing profession that persists to date. This cultural assumption that being a man renders one incapable of working as a nurse, has led to a systemic bias against male nurses that has resulted in the low interest from men in the profession.

The legitimacy of male nurses has been in question globally and here in Kenya as well. The Kenya National Assembly Official Record (Hansard) Oct 8 - Dec 11, 1985 demonstrates the bias that has existed over the years against male nurses. The former M.P for Turkana East, the late Japheth Ekidor, is on record enquiring why the Ministry of Health was yet to post a lady nurse at Lokitaung Hospital. He argued that the male nurse posted at the center was incapable of examining women without the presence of a lady nurse. The enquiry, and the underlying gendered assumption, reflects the longstanding question of the legitimacy of male nurses as well as the negative attitude towards their competence and professionalism.

The involvement of men in nursing has been greatly influenced by social and political dynamics, as well as by prevailing gender concepts i.e. masculine and feminine ideals. The role played by male nurses over centuries has largely been invisible, even, though, it was (and still is) as important as the role played by female nurses. This historical invisibility has led to the assumed designation of nursing as women’s work and contributed to the exclusion men in the profession (Evans, 2004).

An analysis of the history of nursing showed that its mostly an account of the involvement and accomplishments of women, this is regardless of the fact that men have also worked as nurses as long as the profession has been in existence (Evans, 2004; Mackintosh ,1997).

The failure to highlight the contributions of male nurses over the years means that there is little information about their professional background and their historical position in the profession as well. Okrainec (1990), as quoted in Evans (2004), argues that this historical invisibility has led to the perpetuation of the assumption that male nurses are an anomaly. The study of the performance of male nurses in Kenya in selected public health care facilities may contribute towards dispelling these assumptions.

2.1.2 Men in Female-Dominated Positions

‘First of all, a female football coach, like a male nurse is a sin against nature.’(Glee, season 1, episode 01)

The line was meant as a witty swipe in the popular American television series Glee, but was laced with negative gender stereotypes. It also showed the perceived status held by men and women who venture into non-traditional professions such as male nurses which are, as represented by the media, ‘unnatural’ (Weaver et al., 2013).

What would motivate a man to venture into an ‘unnatural’ occupation, as nursing is perceived to be, for men? The study conducted by Simpson (2004) categorised the men who venture into female-dominated positions into three categories: she argues that those who actively seek a career in female-dominated professions are referred to as seekers, while there are those who find the occupation, mostly accidentally, as they make general career decisions and are referred to as finders and finally those who settle into the career after having unsuccessfully and/ or

unsatisfactorily tried their hand in other occupations (mostly male-dominated occupations) who are referred to as settlers.

Simpson (2006) argues that there is a relationship between the motivations and rewards by the men in female-dominated professions. She argues that there are intrinsic and extrinsic rewards drawn from one’s profession. Intrinsic rewards are derived from performing the job, because doing so gives that worker a feeling of accomplishment, mastery and/or self-fulfillment. Extrinsic rewards, on the other hand, emanate from outside the individual, and result from the expectation of receiving external rewards such as a salary, benefits, incentives, promotions and recognition in exchange for job performance (Ledford et al., 2013 pg. 19).

Seekers and settlers are more likely to consider intrinsic rewards as key to a successful career. In the case of male nurses those who join the careers in order to help others in need are more likely to be either seekers or settlers. Finders, on the other hand, are more likely to draw job satisfaction from extrinsic rewards such as a salary, promotion etc. (Smith, 2008).

Hayes (1986) argues that attractions of female-dominated work are less obvious. He argues that the profession’s negative traits are more highlighted such as the lack of prestige and social status and rewards, the challenges to masculinity, and evidence of active parental and school discouragement of boys considering such occupations. Parents and schools are perceived to discourage young men from venturing into these careers due to the low prestige associated with such an occupation, as well as the likelihood of low financial remuneration. It was therefore, important to establish from male nurses the perceived attitude from their parents and friends to the news that they wanted to venture into a career in a female-dominated and equally less prestigious field such as is nursing.

William’s (1992) research on The Glass Escalator: Hidden Advantages for Men in the "Female" Professions concluded that both men and women working in non-traditional occupations come across some level discrimination. However, the forms and consequences of the discrimination vary. The men are perceived to enjoy a better working environment and received preferential treatment since they are more visible as a result of their minority status coupled with the underlying assumption that men tend to be more focused on their work. The drawback for the men was the negative stereotyping which they mainly experienced from people outside of the health profession and some of the clients they served. She argues that there are subtle mechanisms that seem to enhance the position of men in female-dominated positions. This phenomenon is what she refers to as the ‘glass escalator effect’. The glass escalator effect suggests that men who venture into female-dominated positions are likely to get promoted up the ranks hence enjoy an advantage to women in these professions. The perceived rewards that accompany a career in nursing for men are a major motivating factor.

The term token is used to refer to the people identified by their ascribed traits such as sex, race, religious affiliation, ethnic group, age, etc. that carry with them a set of high assumptions about their status and behavior which are highly outstanding from the majority of the population (Kanter, 1977). Tokenism suggests that individuals whose social category is under-represented in particular contexts will face levels of biases due to their increased visibility. Kanter originally used the term in reference to women who were under-represented in American companies at the time. Their token status accounted for their negative experiences at work such as sexual harassment, social isolation and identity crisis etc. The term has been employed to study the experiences of other groups who are minorities in their professions. The analysis of these groups is based on e.g. their race as the minority, their religion that makes them the minority, ethnic background etc. Research on men as tokens concluded that:

“It is very challenging for men to break into what could be irreverently called the ‘old girls’ club’” (Porter-O’Grady, 2007: pg. 145).

This means that men are also likely to face negative experiences in their work which may negatively affect their performance. However, other researchers concluded that the male tokens’ experiences were more positive than negative: they receive special attention due to their heightened visibility (Heikes, 1992), and were more likely to benefit from faster career advancement (Floge and Merrill, 1989). Some of the conclusions of the studies on the experience of male tokens validate William’s (1992) concept of the ‘glass elevator effect’.

There has been a growing acknowledgment that men may experience challenges to their masculinity through working alongside more women and by executing duties that women normally undertake (Lupton, 2006). Various studies conducted on men in the female-dominated occupations revealed different coping mechanisms employed by the men in these roles. Simpson (2004) argues that men in these occupations tend to re-label the jobs and use status enhancement techniques. Re-labeling involves for example male librarians referring to themselves using titles such as 'information manager' or 'researcher', most male nurses identify themselves with the area of specialisation such as theatre nurse, clinical officer, cardiac care nurse, pediatric nurse. Status enhancement strategies involved the articulation of the complexities involved in the occupation as well as citing the qualifications and the responsibilities tied to the occupation. This emphasis by the male nurses on the qualities required for their occupation is a strategy to justify their positions as well as enhance the status of their positions.

Smith (2008) noted that some men associated themselves with their places of work rather than their specific job in case they were asked what their profession is by strangers or by new acquaintances. For example, a male nurse may say he works at Kenyatta National Hospital, or a librarian may say he works at the University of Nairobi. This is a coping mechanism employed by individuals who constantly have to legitimise their profession.

Warming (2005) noted that all the men he interviewed in his study had developed an all-male grouping in their work environment that gave them a chance to discuss masculine issues such as

sports, films or have masculine conversations, play sports and/or go out for drinks after work. The groups were noted to be a key part of the men keeping a sort of distance between themselves and their female colleagues.

Male stereotypes place certain limitations on the male nurses. The stereotypes have been noted to greatly influence the male nurses’ choice of the area of specialisation. Evans (2002) conducted a study, Cautious caregivers: gender stereotypes and the sexualisation of men nurses’ touch. The study details the influence of gender stereotypes on male nurses. Evans noted that as a result of the perception of men as sexual aggressors they are very cautious while touching and caring for patients. Mathieson (1991) argues that prevailing gender stereotypes of men negatively influence the ability of male nurses to develop comfortable and trusting relationships with their patients. As a result there is a sub-conscious or conscious inclination by male nurses to opt for nursing specialties that require less intimacy and patient touching (Evans, 2002; Kauppinen-Toropainen and Lammi, 1993; Williams, 1989, 1995).

2.2 Theoretical Framework

Human Capital Theory

This theory attempts to address the economics of labour. Human capital is basically the semantic mixture of human and capital (Kwon, 2009). The factors of production utilised to generate goods and/ or services which are not significantly consumed in the production process define capital while human beings constitute the subjects (Boldizzoni, 2008). Human capital theory defines the knowledge and/or characteristics a worker either acquires and/ or occurs innately that contributes to his or her economic productivity.

Galor (2011) argues that accumulation of physical capital was regarded as the prime source of economic growth. However, gradually, the accumulation and investment in human capital has morphed into the primary driving force of economic growth and has also substantially altered the impact of inequality on the process of development.

Schultz (1961) posits that human capital is a distinct aspect of the modern economic system. He argues that the fact that people acquire knowledge and skills is rather obvious but what is oblivious is the fact these are the aspects that form human capital. This capital is developed after a deliberate and substantial investment of resources such as time spent in school, finances spent on training etc.

According to Galor and Sicherman (1988) human capital theory is a lifecycle theory. They argue that when individuals choose the levels of schooling and feasible career paths their main aim is to maximise the value of their life time earnings and assure themselves of occupation and occupational mobility as well as a higher likelihood of promotions and increase in remuneration.

Crawford (1991) argues that human capital is characterised by expanding, self-generating, transportable, and shareable aspects. This means that human capital is dynamic and can therefore be increased, diversified and expanded overtime. Human capital development can also be subject to social and cultural biases that restrict the inclusion of individuals in the process of human capital development resulting in discrimination in access for example due to their race, gender, ethnic and religious background. Limiting individuals’ access to the prospects of developing their human capital also translates to limiting their economic potential and productivity. The increase in the number of women venturing into male-dominated roles demonstrates the dynamic nature of human capital development. The same dynamic aspects should also be extended to men who wish to venture into female-dominated professions.

Kwon (2009) argues that the characteristic of human capital focusing on knowledge can be a core element to solve the problem of scarcity in the labour market. Sharing information and knowledge on the available opportunities that exist to all interested individuals can expand the range, reach and diversity offered by developing human capital.

The impact of human capital is generally categorised into three parts: individual, organisation, and society. In the perspective of individual productivity human capital increases the possibility of securing an economically productive occupation, increase in an individual’s income, occupation and occupational mobility as well as status enhancement and mobility (Sidorkin, 2007).

In regards to the organisational impact human capital development is linked to the enhancement of competence and competitiveness of organisations (Snell and Lepak, 1999). Edvison and Malone (1997) also argue that the individuals’ human capital affects the organisation’s human capital in terms of the collective competences, organisational routines, company culture and relational capital. In regards to the social perspective of human capital McMahon (1999) paints the development of human capital as an avenue for fortifying democracy, human rights, and political stability based on an economically empowered society. According to Beach (2009), human capital can increase social consciousness of the community resulting in social, political and economic development.

Investment in human capital is driven by the information available on the opportunities that exist within the labour market that offer the most significant returns. There has been a considerable effort to increase the investment of human capital in favour of women under the gender mainstreaming strategy adopted by the United Nations Economic and Social Council (ECOSOC, 1997).

Human capital theory suggests that investing in the right kind of education and training can empower any individual, regardless of ascribed traits, acquire skills necessary to tackle any economic activity. This has been the premise for encouraging more and more women to venture into male-dominated fields, though with the added incentive of lowered entry requirements such as the lower grade points required for women and girls in comparison to male students when

assessing their qualifications for their entry into learning institutions and such strategies as affirmative action.

Gender mainstreaming human capital investment may lead to a shift in focus on increasing the demand for male nurses and encouraging more health care facilities and health care learning institutions to devise strategies aimed at establishing a gender balance and greater diversity in the profession. Gender mainstreaming human capital development will enable the dissemination of information to men in regards to the opportunities that exist in the professions perceived to be feminine with the aim of establishing gender equality in female-dominated occupations.

Rational Choice Theory

Rational choice theorists argue that individuals are motivated by the wants and/ or goals that express their tastes and preferences. Their actions and choices are guided by specific constraints and the amount of information they have (Scott, 2000).

Rational choice theory aims at understanding social action by analysing the motivations underlying human behavior. The theory offers an explanation on the influences of incentives and constraints on human behavior.

According to Abell (2000) the theory is built on several assumptions. These assumptions include: Individualism and Optimality which influences individuals to ultimately take rational actions and make calculated decisions that are self-interested and self-maximising. Individual choose what they perceive as the best course of action(s), influenced mainly by preferences the opportunities and/or constraints they face. This means that the course of action adopted is the best as perceived by the actor given the set of circumstances at hand.

Self-regard or self-interest which dictates, that the actions of individuals make achieve the best for himself or herself, given the prevailing circumstances.

Rationality dictates that all individuals act in such a way that they attain maximum benefits from every course of action employed.

The theory considers what resources are available to the social actor. The resources can be tangible such as factors of production, social capital and human capital and can also be intangible such as motivation, personal traits, charisma and talent. These resources can be utilised to trade in economic, social or political exchanges. The theory also considers the fact that individuals have unique tastes, Interests and preferences. While these factors are subject to change they are assumed as relatively consistent. The theory also considers that an individual has various courses of social action. Attached to each option is a set of consequences and expected outcomes also referred to as costs and benefits. Individual decisions are considered to draw optimum net benefits in terms of psychological benefits e.g. satisfaction and economic benefits such as monetary reward and ultimately resulting in social mobility (Coleman et al., 1992).

'The elementary unit of social life is the individual human action. To explain social institutions and social change is to show how they arise as the result of the action and interaction of individuals' (Elster, 1989, pg.13)

The entry of men into female-dominated professions is best understood as an issue of social mobility in the context of a gendered labour market environment (Lupton, 2006). Rational choice theory offers a possible premise to understand what influences men to make choices that ultimately result in venturing into female-dominated roles.

Male nurses can be considered as rational individuals who opt for the choice that is likely to give them the maximum satisfaction (Heath, 1976: 3; Coleman, 1973; Carling, 1992: 27; Scott, 2000: 3). Men choosing to venture into female-dominated occupations, in spite of the gender barriers and negative stereotypes associated with it, can possibly be understood as influenced by the characteristics and preferences of the individual men (Dabbs et al., 1990).

Hayes (1986) argued that there are certain factors that attract men to roles perceived as feminine. He argues that occupations in female-dominated fields tend to be less demanding on time and commitment therefore, may be attractive to men who wish to prioritise areas of their life other than a career. Men may also be attracted by the opportunities for sexual exploits afforded by working predominantly with women. William’s (1992) glass escalator may also demonstrate the perception that men in female-dominated occupations have an easier way up the ranks to the top, unlike male-dominated professions which are perceived as intensely competitive.

Jacobs (1993) argues that men have little reason to choose female-dominated jobs since there are more financially rewarding jobs and considering the added disincentive of the challenge to their masculinity presented by female work, which he terms the ‘prestige penalty’. However, the reality of the Kenyan labour market contradicts this argument. The professions considered more financially rewarding are not only very scarce but they are also very competitive. Therefore, this is a significant incentive to consider venturing into female-dominated careers that have a higher labour demand and lower levels of competitiveness since the supply is low.

It can also be argued that men require adequate information and proper understanding of the opportunities that exist beyond the traditional male-dominated occupations. A greater level of understanding and awareness about the existence of male nurses who are performing their duties and responsibilities to the required satisfaction despite the gender barriers imposed on the profession establishes a possibility of increased interest from other men, more so male students, which may result in their increased enrollment into the profession.

2.3 Conceptual Framework A conceptual framework is a set of general ideas and principles derived from the area of study and utilised to construct and structure a subsequent presentation (Reichel and Ramsey, 1987).

This study sought to analyse the performance of male nurses in selected public health care facilities in Kiambu County. The dependent variable was the performance of the male nurses while the independent variable was their gender. The intervening variables in this study were the motivations for entry into the career, the rewards considered most significant by the nurses, the perception of the male nurses towards their profession and the coping mechanisms. The intervening variables collectively were highly likely to enhance and/or limit the dependent variable.

Figure 1: Graphic Representation of the Conceptual Framework

Dependent Variable Intervening Variables Independent Variable

REWARDS

-INTRINSIC e.g. sense of meaningfulness, helping people, EXTRINSIC e.g. pay raises, promotions, bonuses, and benefits.

MALE NURSESAS CARE

MOTIVATIONS

PERFORMACE -INTRINSIC

-EXTRINSIC -WORK HABITS -ATTITUDE (FAMILY -JOB EFFICIENCY AND FRIENDS -COMPETENCE -JOB SATISFACTION

PERCEPTION OF THE -JOB STRAIN -NEGATIVE/ POSITIVE PROFESSION BY MALE NURSES REVIEWS -DISCIPLINARY ACTION -EXTRAVISIBILITY

-ADDED PRESSURE GIVERS -FORMAL CLIENT -ADVANTAGES COMPLAINTS -DISADVATAGES -AWARDS AND/OR - +VE & –VE BIAS COMMENDATIONS -STEREOTYPE-THREAT

COPING MECHANISMS

-RELABLING -MALE-GROUPINGS -ROLE SPECIFICATION -WORK-PLACE SPECIFICATION -ROLE JUSTIFICATION

Source: Author’s Conceptualisation

2.4 Operational Definitions

Motivation for entry into nursing

Motivation is the strong desire and willingness that drives one to engage in an activity or to simply do something. Motivation influences choices, engagement, persistence and performance of individuals. Wigfield et al. (2000) argue that an individual’s behavior is directed by motivation which is crucial for one’s cognition and performance. They further posit that belief in one’s competence was motivational and the individuals who believe in their ability to successfully carry out a given task were more likely to carry out the activity over a longer period, address the activities’ obstacles to complete it and on subsequent occasions choose more challenging activities.

Motivation was categorised into two: I. Intrinsic Motivation- This referred to doing something, such as a career, because it was inherently interesting such as service to other people, enjoying a career, self-fulfillment. II. Extrinsic motivation -Referred to doing something because it led to a separable outcome such as a stable source of income, job security, employment, employment benefits, status and community recognition etc.

It was also important to analyse the attitude of primary social agents i.e. family and friends to the selection of a career in nursing. Family and friends perceived attitude by the potential male nurses may have acted as a motivating or a de-motivating factor to joining the career.

Rewards Rewards were financial and non-financial incentives that accrued employees as a result of their job performance (Zigon 1998). The incentives increased the frequency of positive employee action and their levels of job performance. Rewards were categorised as either intrinsic or extrinsic. Intrinsic rewards referred to the inherent satisfactions drawn from one's job.

1. Intrinsic rewards gave a sense of psychological satisfaction to the employees because they perceived themselves as doing meaningful work and performing it well. Intrinsic rewards were operationalised by analysing; a. Their sense of meaningfulness.

b. Satisfaction drawn from meeting the challenges posed day to day by the nursing profession. c. Praise and esteem.

2. Extrinsic rewards were conceptualised as the tangible benefits, mostly financial, that accrued employees. They were external to the work itself since their quantity and quality was determined by other people such as managers and supervisors. Extrinsic rewards were operationalised by analysing whether employees drew their satisfaction from; a. The level of salary b. Various allowances c. Promotions

Perception of the profession by male nurses Token referred to the perception of individuals or groups of people by their ascribed traits such as sex, race, religious affiliation, ethnic group, age, etc. that carry with them a set of high assumptions about their status and behavior which were highly outstanding from the majority of the population (Kanter, 1977). Based on their gender, male nurses, and their minority status and/ or their under-representation they may have perceived themselves as tokens in the profession.

This variable was operationalised by analysing: a. The male nurses' perception of their heightened visibility in the work place. b. The male nurses' experience(s) of stereotype threat—the expectation that one would be judged or perceived on the basis of a social identity group membership rather than actual job performance and potential. Male nurses were a minority in the nursing profession and would therefore encounter various stereotypes in the course of their careers. c. The male nurses perception of discrimination in the work place by colleagues, superiors and clients. The male nurses' perception of bias treatment (either positive or negative bias) from their fellow colleagues, superiors and clients. d. The male nurses' perceptions of advantages and disadvantages that they accrued as a result of their minority status. The advantages could also be rewards that motivated male nurses to perform their duties well and for long periods of time. The extra-visibility may have,

however, resulted in added pressure, higher job strain and higher level of work stress which may have negatively impacted on the overall performance by male nurses.

Performance Performance was conceptualised as scalable actions, behavior and outcomes that were linked with employees as they contributed to meeting the set organisational goals and laid output standards (Viswevaran and Ones, 2000).

The performance of employees was influenced by the following indicators; a. The employee’s self-evaluation in work habits and job efficiency rates b. Formal complaints c. Disciplinary action d. The level of job satisfaction. e. The level of confidence in one’s competence to meet the job requirements. f. Employee’s performance reviews. g. Awards

Coping mechanism Coping mechanism was conceptualised as the behavioral and psychological strategies that were employed by individuals to handle, adapt, tolerate, reduce and/or minimise situations they deem uncomfortable and/or stressful (Taylor, 1998). Men were more likely to experience challenges to their masculinity through working alongside more women and by executing duties that women normally undertook (Lupton, 2006).

Coping mechanisms was operationalised by analysing whether male nurses had consciously or sub-consciously adopted any of the following strategies; a) Relabeling which referred to altering the title of the occupation and using terms perceived suitable by the male nurse. b) Role specification which referred to individuals identifying themselves with the area of specialisation rather than the general title of the job.

c) Work place specification which referred to men associating themselves with their places of work rather than their specific job. d) Role justification which referred to the articulation of the complexities involved in the occupation as well as laying emphasis on the qualifications and the responsibilities tied to the occupation as a strategy to justify and enhance the status of their occupations e) The formation of male-groupings at work as a strategy to keep a distance between themselves and their female colleagues.

CHAPTER THREE: RESEARCH METHODOLOGY

3.1 Introduction This chapter presented the research procedures and instruments that were used in carrying out this study. The chapter included the site description, research design, sampling, unit of analysis and observation, data analysis and presentation, and ethical issues.

3.2 Site Description The research site was Kiambu County. According to data available from the Kenya Open Data, Kiambu County has an estimated population of about 1,623,282 (Male-49%, Female-51%). The County has a population density of 638 people per km2. The County is estimated to have about 469,244 households.. The County has a doctor to population Ratio: 1:25,000 while the nurse to population ratio is 1:21,940. The infant mortality rates 7/1000 (Kiambu District), 63/1000 (Thika District) while the under five years mortality rates: 8/1000 (Kiambu District), 36.7/1000 (Thika District). The prevalent diseases in the area include: malaria, respiratory tract infections, Intestinal Worms and pneumonia.

According the County Government of Kiambu, the health facilities County-wide were 4 district hospitals, 3 sub-district hospitals, 108 dispensaries, 29 health centres, 170 medical clinics, 9 nursing homes, 1 maternity homes, and 22 listed as others. Kiambu County was selected for the study because it has one of the highest number of nurses stationed in various public and faith- based hospitals. According to KNWR (2012) Kiambu County is estimated to have about 1,130 nurses, the second highest number deployed to the various public and faith-based health facilities in Kenya after Nairobi County which is estimated to have about 2,785 nurses.

Figure 2: Map of Kenya showing the specific study area highlighted in red

Source: County Government of Kiambu

Figure 3: Administrative Map of Kiambu County

Source: County Government of Kiambu

The research sub-sites selected were four public health facilities and a faith-based health facility. As noted in KNWR (2012) the available data on deployment of nurses in Kenya covered only public heath care facilities and faith-based facilities. There was little data on the deployment of nurses in Private facilities since most did not share their information with the Ministry of Health. This lack of data led to the exclusion of private healthcare facilities in this study. The four public health facilities were selected based on the size from the biggest facility in the County, to the moderate in size and the smaller facilities serving local communities. The researcher opted to include only one Faith-based Facility guided by the fact that approximately for every 2.29 public health facility there is one faith-based health facility (KNWR, 2012).

The sub-sites were also selected due to their long history since they were all established before 1965, the size of the facility based on services rendered and number of patients attended to and the nursing size of the workforce. The facilities were also chosen due to the ease of access and a limited budget for the study.

The specific sub-sites were:

a) Thika Level 5 Hospital. The hospital was constructed in 1941 as a native hospital and opened its doors in 1942. The hospital's status was upgraded in 2009 when it was gazetted as a Level 5 hospital from its previous status as a Level 4 health facility. The hospital has developed over the years into the largest public health facility in Kiambu county. The hospital is situated along General Kago Road, Thika town. The hospital has a bed capacity of about 300 and about 25 cots. The hospital operates 24 hours a day. The services available in the facility included antenatal, antiretroviral therapy, basic emergency obstetric care, caesarean section, comprehensive, emergency obstetric care, curative in-patient services, curative outpatient services, family planning, growth monitoring and promotion, HIV counseling and testing, home-based care, immunization, integrated management of childhood illnesses, prevention of mother to child transmission of HIV, radiology services for example X-ray, Ultra-scan, MRI, tuberculosis diagnosis and tuberculosis treatments. The hospital had about 240 nurses out of which only 15 (6.25%) were men.

b) Kiambu District hospital The health facility is located in Kiambu East District, and in Kiambaa Division opposite the Kiambu law courts and is currently under the care of Kiambu County . The hospital is one of the 4 district hospitals in Kiambu County. The hospital was undergoing upgrades during the data collection period to become a level 5 facility. The services available in the hospital include ante-natal, basic emergency obstetric care, curative outpatient services, family planning, growth monitoring and promotion, HIV counseling and testing, immunization, prevention of mother to child transmission of HIV, tuberculosis Labs, tuberculosis treatments and a host of other services. The hospital had total of 185 nurses with men making up only 11% (21 male nurses).

c) Karuri sub-county hospital. The hospital has been in operation since 1963 making it one of the oldest government medical centers in the country. This was listed as a sub-district hospital which was a level 3 facility with a bed capacity of about 18. However, the hospital was undergoing upgrades during the data collection period to become a level 4 facility. The Karuri Health Centre is located in a Karuri, Banana Hill, and provides 24-hour outpatient treatment to a population of 50,000-10000 people. The hospital had about 22 nurses out of which only 2 were men. That was about 9% of the work force.

d) Wangige Sub-county Hospital The construction of the health facility started in Late 1965 and was officially opened as a the Wangige Self-help Maternity Ward in 1969. The facility had largely served as a level 3 community health center but was undergoing upgrades during the data collection period to become Level 4 hospital serving the people of Kabete sub-county. The services available at the health facility included anti-retroviral therapy, family planning services, mother child health care, home-based care, inpatient department and outpatient department. The hospital has a bed capacity of 10. The nursing staff was made of 15 nurses out of which only 13% (2) were men.

e) PCEA Kikuyu Mission hospital. The hospital is owned by the Presbyterian Church of East Africa, (P.C.E.A.). It was founded in 1908 by Scottish Missionaries, as a small first aid center. The Hospital has been in operation for a little over a century making it one of the oldest health care facilities in Kenya. The hospital has developed from its humble beginnings to its current stature as a major mission hospital. The hospital has four units the general unit, the eye unit, the orthopaedic unit and the dental unit which offered an array of medical services. The hospital had about 118 nurses out of which only 12% (14) were male nurses.

3.3 Research Design The research employed the descriptive research design which was used to gather both quantitative and qualitative data. Descriptive research is a method of gathering information by interviewing and/ or administering questionnaires to a sample of individuals (Orodho, 2003). Orodho and Kombo argued that descriptive research design can be used when collecting information in regards to individuals attitudes, habits and opinions or any of the variety of education or social issues.

This study employed questionnaires as the instrument of the research to gather mostly quantitative data. The questionnaire was developed guided by using questions used by Smith (2008), Warming (2005) and Simpson (2004) in their research. The questions were modified to suit the specific objectives of this particular study.

The questionnaire eased conducting research which required multiple respondents and acquisition of a significant amount of information. It also offered anonymity and safeguarded the respondent‘s right to privacy and confidentiality. However, the use of questionnaires was limiting due to the fact that a) The closed questions in the structured interview questionnaire may have limited the respondent’s chance for further explanation and/ or probing by the researcher. b) Respondents may have been be uncomfortable providing answers that may have presented them unfavorably which may have resulted in non-response of some questions and/or inaccurate responses to some questions.

The study also used face to face interviews with the 5 selected key informants to gather qualitative data. The interviews allowed gathering data for an in depth understanding of the performance of male nurses.

3.4 Unit of Analysis and Units of Observation According to Mugenda and Mugenda (2003), these are the units that are designed for purposes of aggregating their characteristics in order to describe some larger group or abstract phenomenon. In this study, the unit of analysis was the performance of male nurses working as care givers in selected public health care facilities in Kiambu. The units of observation were male nurses who participated in this study as respondents and their supervisors who were selected as key informants.

3.5 Sampling Male Nurses The target population for the study was all the registered male nurses serving in the five research sub-sites. Due to the limited number of male nurses working in all five research sub-sites, which was about 54 registered male nurses, the researcher opted to sample the entire population. The sample was made up of all the male nurses who were in the five hospitals during the data collection period which was 49 nurses. One of the nurses declined to take part in the study. This left a sample made up of 48 male nurses as shown in Table 1. The rest (5 nurses) were unavailable because they were on leave.

Table 1: Number of male nurses sampled Research sub-sites Total Number of male nurses Number sampled Thika Level 5 Hospital 15 14 Kiambu District Hospital 21 19 Karuri Sub County Hospital 2 2 Wangige Sub- County Hospital 2 2 PCEA Kikuyu Hospital 14 11 Total 54 48

Key informants The study also included 5 key informants. They were a deputy matron who had about 10 years experience as a nurse and part of that time spent in a supervisory capacity, a unit supervisor who had over 18 years experience as a nurse and part of that time, about 10 years, in a supervisory capacity, a head of department who had about 25 years experience working as a nurse and part of that time over 15 years in a supervisory capacity and managerial capacity, a director of nursing services who had over 19 years experience as a nurse and a senior nursing officer who had worked for over 24 years as a nurse and part of that time, about 14 years, in a managerial position. All of the key informants were drawn from the five sub-sites, who provided more information on the performance of male nurses working under their supervision.

3.6 Data Collection and analysis The male nurses were interviewed using questionnaires while interview guides were used for the key informants.

3.6.1 Type of Data This study sought primary data relating to the performance of male nurses in public health facilities by purposively targeting five health facilities in Kiambu County. This study specifically sought information relating to the motivations, experiences, performance and coping mechanisms of male nurses as well as the challenges they faced in a profession that was perceived to demand qualities that were traditionally associated with women.

3.6.2 Data Analysis Methods and Presentation Descriptive statistics was employed to analyse the quantitative data that was collected using questionnaires. This was done using graphs, percentage distributions, pie charts, and means, calculated and tabulated using the statistical package for social sciences (SPSS) software. The qualitative data, collected through key informant interviews, the open-ended questions on the questionnaire and further information sought from some of the respondents was analyzed for content that would be used to support other findings from the study. The information was

organized, summarized and presented in direct quotations of relevant verbatim responses and selected comments. Narrative analysis was employed.

3.7 Ethical Issues When conducting this study, an introductory letter from the Department of Sociology, University of Nairobi, was used to introduce the researcher and purpose of the intended research. The researcher also used the participant information and consent forms to ensure that the respondents knowingly and willingly agreed to participate in the research. Those who wanted to withdraw from the study at any particular time were at liberty to do so. The anonymity and confidentiality of the respondents was guaranteed by using serial numbers on the questionnaires instead of their names to conceal their identity for their safety, dignity and privacy.

CHAPTER FOUR: DATA ANALYSIS, PRESENTATION AND INTERPRETATION

4.1 Introduction This chapter presented the findings of the study on the performance of male nurses as caregivers in Kiambu County. It was organised into thematic areas as based on the objectives of the study stated in chapter one which were: to identify the motivations for entry into the career, the rewards the male nurses considered most important, the male nurses' perception of their career, self- evaluation of their performance and the coping mechanisms they employed to deal with the female-dominated work environment.

4.2 Characteristics of the male nurses

4.2.1. Age Distribution From the sample population of 48 nurses, a majority of the respondents (33%) were found to be between the ages of 25 and 29. The respondents who were between the ages 30 and 34 were19% and the same percentage for those between 35 and 39 years. Whilst, 13% were 24 years and below whereas, those aged between 50 and 54 were 8%. The respondents aged between 40 and 44 were 6%, while, those between 45 and 49 were 2%. None of the respondents were 55 years and above.

Figure 4 :Respondent's Age

2% 8% 13% 24 & below 6% 25-29 19% 30-34 33% 35-39 40-44 19% 45-49 50-54

Saks and Waldman(1998) research concluded there was no relationship between age and job performance of employees, however, age was important in this study because it was highly likely that the older nurses had different motivations for entry into nursing, different reward value systems and adopted various coping mechanisms for working in a female-dominated profession when compared to the younger nurses.

4.2.2 Marital status The respondents who were married were 54.2%, those who were single were 43.8% while 2.1% were divorced. Ryu and Kol (2002) research showed that there was a positive relationship between an employee's marital status and better job productivity. Married employees were more likely to perform better on the job compared to the unmarried employees.

Figure 5: Marital Status Percent 60

50 54.2

40 43.8 30 single married 20 divorced/ separated 10 2.1 0 single married divorced/ separated

4.2.3 Education level A majority of respondents (68.8%) had a college diploma , while 27.1% had a university undergraduate degree, and a minority (2.1%) had a post graduate diploma and a similar percentage had a college certificate. Ng and Fieldman (2009) in their research concluded that

educated employees performance was more effective. Thus, there was a positive relationship between higher levels of education and better job performance.

Figure 6: Level of education

68.8 80

40 27.1

20 2.1 2.1

0 college college diploma university post graduate certificate undergraduate

college certificate college diploma university undergraduate post graduate

4.2.4 Years of Experience as a Nurse Table 2 revealed that a majority of the respondents (39.6%) had worked as nurses between 2 and 5 years, whereas, 25% had worked for one year and/or less. About 16% had worked for between 6 and 10 years, while 10.4% had over 15 years experience. Those who had between 11 and 15 years of experience were, 8.3%. Experienced workers were more likely to have better job performance due to expertise gained in execution of duties over a long period.

Table 2: Respondents years of experience Years of experience Number of respondents Percentage frequency

0-1 12 25.0 2-5 19 39.6 6-10 8 16.7

11-15 4 8.3

Over15years 5 10.4 Total 48 100.0

4.3 Motivation for entry into nursing The first objective of this study was to understand the prevalent entry pattern into a career as a male nurse. This research categorised motivation in two categories Intrinsic and extrinsic. Intrinsic Motivation was defined as engaging in an activity and/ or doing something, such as a career, because it was inherently appealing and gratifying such as through service to other people, self-fulfillment. Extrinsic motivation on the other hand referred to doing something because it led to a separable outcome such as a stable source of income, job security, employment benefits, status and recognition.

Table 3, listed statements whose objective was to establish whether the respondents were motivated by intrinsic and/or extrinsic values when they ventured into the profession. The respondents who were motivated by a passion for helping others, admiration for nurses and influence from a role model were more likely to espouse intrinsic motivation while those who were drawn by the good financial benefits, possible opportunities for men in nursing and took up nursing because they were academically qualified through KCSE were more likely to be extrinsically motivated.

Table 3: Factor(s) which motivated the respondents to venture into nursing Agree Strongly Neutral Disagree Strongly Total (N) Statements on motivating factors (%) Agree (%) (%) (%) Disagree (%) a. I had a passion for helping people and 25.0 41.7 27.1 0 6.3 100 48 nursing was the best way. b. I admired nurses. 10.4 18.8 43.8 16.7 10.4 100 48 c. I was influenced by a role model. 18.0 12.0 20.0 32.0 18.0 100 48 d. Nursing offered good financial benefits 4.2 39.6 33.3 12.5 10.4 100 48 and opportunities for men. e. I chose nursing because that is what my 14.6 25.0 16.7 22.9 20.8 100 48 K.C.S.E grades qualified me for.

The aim of the first statement was to establish whether passion for helping people was a motivating factor. A majority of the respondents (66.7%) either strongly agreed or agreed with the statement. In contrast, a minority 6.3% strongly disagreed with the statement while 27.1% were

neutral to the statement. This indicates a majority of the respondents placed importance on intrinsic values when they made their career choice.

The second statement sought to establish whether admiration for nurses was a motivating factor. Majority of the respondents, 47.1%, either strongly disagreed or disagreed with the statement. In contrast 27.1% strongly agreed or agreed with the statement while 45.8%, held a neutral opinion. A respondent who was in the 50-54 years age bracket and had over 15 years experience disagreed with the statement and said;

"When I went to college for nursing I was a lone young man in a group of many ladies. As far I can recall I did not know any male nurses so it is hard to say that I got into the profession because I admired nurses."

Statement 3 sought to establish how many of the respondents were influenced by a role model. According to the results only 30% knew an individual who was a role model who inspired them to join the profession. There is a considerable failure to highlight the role played by male nurses over the years which has subsequently contributed to the low number of young men viewing nursing a possible career.

The 15 respondents who indicated that they were influenced by a role model were asked to identify who the individual was i.e. how they knew the person, gender and occupation. All the respondents indicated the role model was male and working either as a nurse or a clinical officer. 10 of the respondents indicated that the role model was a relative. A male nurse who had over 15 years experience gave additional information and said:

"My grandfather worked as a dresser during colonial times so the influence was from an early age. I was exposed to the opportunities in the profession early enough."

Four of the respondents said their role model was a family friend. A single respondent, who was in the 25-29 years age bracket, indicated that his role model was a former school mate. He said:

"I ran into him while he was working at a public hospital. I actually thought he was a doctor but he clarified that he was an enrolled nurse. At the time, I had no idea that nursing could be a career for men. After I talked to him about the profession and he made me see the possibilities in the field, I was hooked. He played a very significant role in influencing my decision to venture into nursing."

In contrast, 50% either strongly disagreed or disagreed that they were influenced by a role model while 20% were neutral to the statement.

O’Lynn (2004) studied the gender-based barriers that male student nurses encountered in school and how nursing education programs had failed to attract more males to the nursing profession. In her findings she noted that lack of role models for the men was a major barrier for male students in nursing.

Statement 4 analysed the value the respondents placed on the possible favourable financial benefits and opportunities for men in nursing which was an extrinsic motivating factor. A majority of the respondents (43.8%) either strongly agreed or agreed with the statement. In contrast, 22.7% of the respondents either strongly disagreed of disagreed with the statement while 33.3% of the respondents were neutral. This indicated that financial benefits, which was an extrinsic motivating factor, was an important influencing factor for most of the respondents.

Statement 5 sought to establish whether the respondents settled for nursing as a result of the grades they attained after KCSE. A majority of the respondents (43.7%) either strongly disagreed or disagreed that the grades played any role in determining their choice of nursing as a career. The respondents who either strongly agreed or agreed that the grade they got in KCSE was influential in the choice of career to pursue were 39.6%. Those who had no opinion on the statement were 16.7%. KCSE grades in this study were listed as extrinsic motivating factors because the choice of careers was made by factors external to the respondent. Quite a significant number of the respondents (39.6%) were influenced by their KCSE grades which demonstrated its importance as a motivating factor.

Table 4, indicated how the respondents entered into nursing. Based on the categorisation by Simpson's (2004) research the respondents who can be grouped as seekers were those who joined nursing because they were influenced by a role model at an early age. Those who attended a career seminar and/or those who joined nursing after KCSE were categorised as finders. Settlers, on the other hand, joined nursing after a period of unemployment and/or after trying other jobs. Majority of the respondents, 35.5%, were finders. Seekers made up 27.1% of the respondents while settlers made up 22.9% of the respondents.

In the study conducted by Smith(2008), the largest group found in her research was finders at 45%, followed by settlers who were 37% and the smallest group was seekers at 18%.

There were 12.5% of the respondents who listed 'other' as their response. A respondent who indicated he had about 11-15 years experience and had listed 'other' in response to the query, remarked that he vividly recalled how he ended up in nursing. He said:

"After my KCSE results were out I applied for clinical medicine but when my appointment letter came it was for nursing. It was not my wish to get into nursing and I still feel bad till today that I go into the wrong career. But I have resigned to the fact that my fate was sealed a long time age."

Table 4: How the respondents joined nursing

Influencing variables Number of respondents Percentage frequency

Career seminar 3 6.3 Role model 13 27.1 After KCSE 14 29.2 After trying other jobs 7 14.6 After unemployment 5 10.4 Other 6 12.5 Total 48 100.0

The analysis of the responses from the respondents indicated that majority of the respondents balanced between intrinsic and extrinsic motivations. Most of the respondents derived motivation from both intrinsic and extrinsic motivations. This showed that while self fulfillment and enjoying one's choice of career was important financial benefits attached to the career chosen was an equally important motivating factor when attracting young people.

Table 5 detailed the period in time when the respondents decided that they wanted to venture into a career in nursing. More than half of the respondents (54.2%) decided they wanted to be nurses when they were young adults (between 20-29 years), while 39.6% when they were teenagers (13- 19years) and only 6.3% when they were in their childhood (12 years and under).

Table 5: When respondent decided to venture into nursing Time Periods Number of respondents Percentage frequency

Childhood(12 yrs & under) 3 6.3 Teenager(13-19 yrs) 19 39.6 Young adult(20-29 yrs) 26 54.2 Total 48 100.0

Only 6.3% of the respondents had noted that nursing was a possible career path at childhood. This indicates that very few young boys see nursing as a possible career.

All the key informants, who were interviewed, were female. When the key informants were asked the same question 4 out of 5 indicated that they wanted to be nurses when they were very young girls (12 years and under). A key informants, who was a head of department said:

"There was something about the nurses and their beautiful uniform that I fell in love with. I was around 6 or 7 years when I told to my parents that I wanted to be a nurse when I grew up. I have been a nurse for 22 years and still counting."

Only a single key informants, the director of nursing services in of the research sub-sites, indicated that she decided to be a nurse past childhood, i.e. in her teenage years, specifically when she was in form two.

Miller and Budd (1999) noted that while girls are learning from an early age to have a more liberal approach to the choices they make in regards to career decisions there is a particular difficulty to persuading boys, and men in general, to consider traditionally feminine areas of work.

The respondents were then asked how much information they had about the opportunities in nursing before they entered the profession. This was important to establish, since, actions and choices were guided by specific constraints and the amount of information that was available to an individual about the circumstances under which they were acting (Scott, 2000). The question sought to ascertain whether the decision was borne out of a rational choice, as well as, how many of the respondents actively researched before they made a sound decision about nursing as a career.

Table 6 shows that a majority of the respondents, 45.8%, indicated they did not know about the opportunities for men in nursing, while in contrast, 43.8% of the respondents indicated that they knew. The respondents who indicated that they had no recollection were 10.4%.

Table 6: Prior information on opportunities in nursing Response options Number of male nurses Percentage frequency Yes 21 43.8 No 22 45.8 Don't remember 5 10.4 Total 48 100.0

As seen from the results on Table 6, a lot still needs to be done to increase the amount of information available to young men when they are making career choices so that many more are aware that nursing is an option with many opportunities for them.

It was also important to analyse the attitude of primary social agents i.e. parent(s) to the selection of a career in nursing. The perceived attitude of the parent(s) by the potential male nurses may have acted as a motivating or a de-motivating factor to join the career. Majority of the respondents (92%) indicated that their parents were supportive. In contrast 4% indicated that they were not supportive. Those who indicated that their parents were indifferent were 2% while another 2% indicated they did not know.

Figure 7: Attitude of Parents

2% 2% 4%

Supportive Not supportive Indifferent Don't know

92%

When asked whether the perceived attitude of their parents towards their choice of career affected and/or influenced their decision to enter into nursing, a majority, 67% acknowledged that it did.

On the contrary, 33% said it did not. Most of the respondents indicated that they received moral and financial support to pursue the careers that they wanted. Majority of the respondents felt that their parents would have supported them which ever career they opted for. It was also noted that quite a number (42.7%) of the respondents indicated that their fathers' support was a major motivating factor.

This was similar to the findings of the research conducted by Warming(2005 pg.22). The men describe their families’ reactions to their career choice as encouraging. Warming noted that the respondents in his study said they were not confronted with opposition but with a high degree of backing and understanding.

Figure 8: Whether the attitude of parent(s) had an impact on the respondents

No 33%

Yes 67%

A young male nurse, in the 25-29 age bracket, indicated he received support from both parents said:

"My parents were both in the medical professions and thus when I identified nursing as my career choice they were not only supportive but they guided me in my studies and making crucial career goals in nursing."

Another respondent who was older, in the 45-49 years age bracket, indicated that he also received support from his parents. He said:

"My parents believed it was a good profession. I remember my father telling me that nursing was very marketable in and out of the country so I should not

to worry about what people said about being a man in nursing but to go ahead and pursue it."

A respondents, in the 24 years and below age bracket, who indicated that the perceived attitude of his parents did not influence his decision said:

"I had made up my mind by the time I told them that I wanted to pursue a career in nursing. I am very head strong so I was going to do it no matter their opinion."

It was evident that the prevalent entry pattern for male nurses who participated in this research was: Most decided to join the profession at 20-29 years of age. Most had little or no information about the opportunities for men in nursing. Most of them did not benefit from having role models, as a result finders were a majority in this study. The respondents balanced between intrinsic and extrinsic motivation. Majority received full support from their parents which was a very important validation of their career choice.

4.3 Rewards The second objective was to identify the rewards that the respondents perceived as important for the male nurses to realize a successful career as care givers. Rewards were categorised in two intrinsic and extrinsic rewards. Intrinsic rewards gave a sense of psychological satisfaction for the employees because they perceived themselves as doing meaningful work and performing it well. On the other hand extrinsic rewards were tangible benefits, mostly financial, that accrued employees. They were external to the work itself since their quantity and quality was determined by other people such as managers and supervisors.

The research analysed whether the respondents perceived their care giving role of nursing fitted in with their character. A majority of the respondents (90%) indicated that they thought their character fitted in well with their role as care givers. In contrast, 10% of the respondents indicated that it did not.

Table 7:Whether the respondents character fitted in with the care giving role Response options Number of respondents Percentage frequency No 5 10 Yes 43 90 Total 48 100.0

When asked to expound the respondents cited various reasons for their responses. Most respondents who affirmed that the care giving role of nursing fitted in with their character indicated that they loved and/or had a passion for helping people which complimented their role as nurses. Some cited that their character traits of compassion, empathy and kindness to others synchronised with their role as nurses.

Most of the respondents who indicated that the care giving role did not fit in with their character did not explain why they held that opinion. The only respondent provided an explanation was in the 35 to 39 years age bracket and working as a theatre nurse. He said:

"I generally do not like dealing with people."

It was important to establish whether the respondents valued intrinsic rewards in regards to the success of their careers. As demonstrated majority of the respondents found a sense of psychological satisfaction from working as care givers.

As indicated in Figure 8, a majority of the respondents (37%) stated that they earned a gross salary of between Ksh.31,000 and Ksh.40,000 while a minority earned a salary of between Ksh.41,000 and Ksh.50,000. The rest 29% earned between sh.21,000 and sh.30,000 while 19% earned sh.51,000 and above. According to the KNWR (2012) in Kenya's public sector, a majority of nurses (56%) earn between Kshs.31,020 and Kshs.41,590 which was confirmed by a majority of the responses from the respondents as seen on Figure 8. Though most of the respondents expressed dissatisfaction with the pay it was worth noting that according to the World Bank data (2015) the average national income in Kenya was about Ksh.133,000 per annum considerably below what the nurses make per year.

Figure 9: Responds' gross monthly salary

The respondents were asked to identify other benefits and/or rewards they received in their career that they valued. Majority of the respondents (78%) cited more financial benefits such as extraneous, house and commuter allowances and good medical cover and getting promoted up the ranks, a minority (20%) listed intrinsic rewards such as community service and assisting those in dire need. 2% of the respondents did not provide additional information.

Table 8 below shows the respondents who had received a promotion as a result of their work. Promotion was identified as an important extrinsic reward for the male nurses which also doubles up as a performance motivating factor. A majority of the respondents, 62.5%, indicated that they were yet to receive a promotion. In contrast, a minority, 37.5%, indicated that they had received a promotion.

Table 8: Respondent's who had received a promotion Response options Number of respondents Percentage frequency Yes 18 37.5

No 30 62.5 Total 48 100.0

As indicated on Table 2, 25% of the respondents had very little experience (0-1 year) therefore, logically, limiting their chances of being granted a promotion. The respondents who said they had not received a promotion gave various possible reasons why that was the case. Some of the

respondents indicated that their work was contract based therefore there was no possibility of promotion unless they renegotiated the terms of their contracts. Those who worked in the county government hospitals listed administrative delays in promotions.

A nurses who was 45-49 age bracket, who also had between 11 and 15 years experience, indicated that he actively opposed all efforts aimed at promoting him adding that he refused for personal reasons. He said:

"I have actively resisted any attempts to being promoted to a managerial position. That would limit my ability to pursue other interest outside of this hospital." When asked to clarify what he meant by 'pursuing other interests' he said:

"I run a private clinic and at times take on locum to supplement my income. That requires flexibility on my part and taking on more responsibilities in the hospital reduces my ability to do all of that."

The respondents were asked to rate their satisfaction with the extrinsic rewards i.e. the conditions at their work in terms of salary, benefits and allowances that they received. A majority of the respondents (62.5%) indicated that the conditions were either very unsatisfactory or unsatisfactory.

Table 9: Respondents rating their work conditions Levels Number of respondents Percentage frequency Satisfactory 4 8.3 Neutral 14 29.2 Unsatisfactory 17 35.4 Very unsatisfactory 13 27.1 Total 48 100.0

In stark contrast, only a minority, 8.3%, considered the conditions satisfactory. 29.2% had no opinion on the statement. This indicated that most of the male nurses were largely unsatisfied with the conditions at work.

The respondents were asked to identify additional rewards that they thought would improve the performance of nurses. Majority of the respondents indicated that a better remuneration package was the best motivator. A young nurse who had 2-5 years experience and was working as an emergency nurse at the out-patient unit said;

"There should be an increase in the number of off duties especially after night duties which are usually very strenuous."

Another male nurse working in the maternity unit and in 30-34 years age bracket said:

"There are so many nurses who want to improve their skills by going for further training but most of us cannot afford it. Providing sponsorship for those who want to pursue further education would be very positive."

A more radical approach was proposed by a young respondents, a university graduate who was 24 years and below with less than one year experience who said:

"There should be a distinction of the work done by the nurses based on the level of education. The duties should be allocated in hierarchical system from certificate holders progressing upwards. This would motivate nurses to actively pursue further training at the earliest possible opportunity."

Agezegn et al. (2014) in their study noted that nurses who were not satisfied at work were also found to distance themselves from their patients and their nursing chores, resulting in poor quality of care for patients, low productivity, and staff turnover which is ultimately very costly to health care facilities. it was noted that the respondents valued both intrinsic rewards derived from being a nurse. However, a majority of the respondents took exception to the remuneration package they received. This was likely to demoralise the male nurses as they play their role of care givers.

4.4 Male nurses’ perception of their profession The third objective was to analyse the respondents' perception of their profession from their perspective as a minority. The minority status may lead to a perception of a token. This referred to the perception of individuals or groups of people by their ascribed traits such as sex, race, religious affiliation, ethnic group and age that carry with them a set of high assumptions about

their status and behavior which are highly outstanding from the majority of the population (Kanter, 1977).

Table 10 listed statements that aimed to establish whether the male nurses perceived themselves as tokens in the profession because of their gender and their minority status and/ or their under- representation.

Table 10: Respondents perception of their profession Statements Strongly Agree Neutral Disagree Strongly Total (N) Agree (%) (%) (%) Disagree (%) (%) (%) 1 Male nurses are more visible than 20.8 20.8 27.1 20.8 10.4 100 48 female nurses. 2 I feel pressure from within myself 41.7 33.3 12.5 6.3 6.3 100 48 to move to a higher position within nursing 3 Supervisors and/or bosses put 8.3 13 43.8 20.8 100 48 pressure on me to move to a (27.1% higher position within nursing. ) 4 Family members and friends put 12.5 29.3 20.8 31.3 6.3 100 48 pressure on me to move to a higher position within nursing. 5 Male nurses tend to be promoted 4.2 14.6 39.6 41.7 100 48 faster and to higher positions than female nurses.

The first statement sought to establish the visibility of male nurses. A majority of the respondents (41.6%) either strongly agreed or agreed with the statement that male nurses were more visible as opposed to their female counterparts. In contrast, 31.2% strongly disagreed or disagreed that male nurses were more visible. The rest of the respondents (27.1%) held a neutral opinion to the statement. Heightened visibility at work for the male nurses as a result of being gender minority enhanced their token status in the work place.

The key informant who worked as a head of department agreed with the statement that male nurses are more visible. She said:

"Male nurses are very few, for example I have only 2 in my department, I have to agree they do stand out."

However, as observed during the research, the visibility of the male nurses was apparent only to the hospital staff and those already acquainted with the male nurses. The dress code of the male nurses actually obscures the male nurses. The patients frequently referred to the male nurses as 'daktari' (meaning doctor) when addressing them. The NCK regulation stated that male nurses wore navy blue or brown coloured pair of trousers and a white shirt with a white lab coat. The regulations were not strictly followed hence the male nurse dress code was very similar to what doctors wore.

Statement 2 sought to establish whether the men put pressure on themselves to advance to higher ranks within nursing. This was important to understand whether the men placed any value to moving beyond their position as care givers. Most of the respondents (75%) acknowledged that they put some level of pressure on themselves to advance in nursing. However, most of those who held this opinion were looking to advance to other organisations especially the non-governmental organisations that they perceive to have better pay. Some of the younger nurses indicated that they were working to get the experience and then move on to what they called better jobs mostly in the non-governmental organisations. As noted by the director of nursing services, in one of the health care facilities, there is a high turnover of the male nurses especially those working in surgical nursing moving on to seek greener pastures.

Statement 3 sought to establish whether the male nurses were subject to pressure from their supervisors and/or their bosses. This was important to understand whether the people who worked with the male nurses pushed them to seek either managerial positions or roles beyond the average role as care givers. A majority of the respondents 64.6% either strongly disagreed or disagreed with the statement that their supervisors and/or bosses put pressure on them to seek higher positions within nursing. A minority, 8.3%, of the respondents affirmed the statement that they received pressure from their superiors to move to higher positions in nursing.

A male nurse who had 11-15 years experience who agreed with the statement said:

”The senior nurses and hospital administrators are constantly asking me to take up a managerial position. With the years of experience I have I think I only need to express interest."

27.1% of the respondents indicated that they had no opinion on the statement.

Statement 4 analysed whether the respondents felt any added pressure from family and friends. This was important to understand whether the family and friends of the respondents placed value on them moving beyond their position as care givers. Majority of the respondents (41.8%) either strongly agreed or agreed with the statement while in contrast, 37.8% of the respondents either strongly disagreed or disagreed with the statement while 20.8% indicated they were neutral to the statement. A male nurse working in post-natal unit the who affirmed the statement said:

"Most people have a low opinion of bedside nursing and assume that is the sole job description of nurses. I have been the subject of thinly veiled jokes about dressing wounds and tending to patients who have soiled themselves. I think that counts as pressure to seek a more prestigious position e.g. a supervisor or head of department etc."

The last statement looked into whether the respondents tended to be promoted faster compared to the female nurses because of their limited numbers and their gender. There is an assumption that due to their limited numbers the male nurses may enjoy the fast lane to promotions. A majority of the nurses (81.3%) either strongly disagreed with the statement or disagreed that male nurses tend to be promoted faster and to higher positions than female nurses. Only 4.2% of the respondents held a contrary opinion and agreed with the statement while 14.6% of the respondents indicated their opinion was neutral. A male nurse working in the eye unit said:

"Consideration for promotions is tied to a lot of factors and I think gender plays a very minute role, if any, to influence the outcome."

The head of department from the faith-based facility said:

"Gender can be influential in getting the male nurses noticed faster but it plays no role in the factors that lead to one's promotion. We mostly look at the experience the nurse has accumulated, the performance of the nurse, specialised training, individual conduct, individual initiative, expertise in execution of duties and the level of education is a significant added advantage etc."

This contradicts Williams(1992) glass escalator findings that men are likely to be promoted faster as a result of their gender in female-dominated professions.

There were perceptions, negative and positive, commonly associated with men in nursing in the literature and media. The respondents were asked a series of statements that highlighted different situations where male nurses were likely to experience stereotypes.

Table 11 details the responses of the respondents when they were asked whether they had experienced a situation where their role as care givers was perceived as too feminine and/or assumed less masculine. At least half of the respondents (50%) had experienced the stereotype but not very often, while, 12.5% indicated they had experienced it either very often or somewhat often. In contrast 37.5% indicated that they have never experienced it.

Table 11: Role perceived as feminine Rate of occurrence Number of respondents Percentage frequency Very often 2 4.2 Somewhat often 4 8.3 Not very often 24 50.0 Never 18 37.5 Total 48 100.0

The respondents were asked whether they had encountered the stereotype of their job being labeled as an “easy job” as seen on Table 12. This was the assumption that they chose to engage in nursing because the men could not fit into a more mainstream, traditional and more demanding male occupation and must have been in nursing because it is easy, safe and less demanding. 50%

of the male nurses said they had never experienced the stereotype. In contrast, 43.8% indicated they had experienced it but not very often while 6.2% indicated they had somewhat often experienced it.

Table 12: Role perceived as an 'easy job'

Rate of occurrence Number of respondents Percentage frequency somewhat often 3 6.2 not very often 21 43.8 Never 24 50.0 Total 48 100.0

The respondents were asked to indicate whether they had ever been perceived as 'womanisers' because of their choice of career as seen on Table 13. This was the assumption that one joined the profession because it was a way to “pick-up” and date women and/or treat them as sexual objects.

Table 13:Respondent perceived as a 'womaniser' Rate of occurrence Number of respondents Percentage frequency Very often 2 4.2 Somewhat often 3 6.2 Not very often 9 18.8

Never 34 70.8 Total 48 100.0

Majority of the respondents, 70.8%, indicated they had never experienced the stereotype. About 18.8% indicate they had experienced it but not very often while 6.2% had experienced it somewhat very often and 4.2% had experienced it very often.

During the interviews when the deputy matron was asked whether there were clients who preferred services from the male nurses she said:

"I have a male nurse in the maternity who is very popular with the women. I became very concerned about this open preference for his services by the female patients because even when he was not on duty the patients would still ask for him. I decided to investigate whether there was more to this preference than meets the eye. I asked a few of the patients why they liked him, and to my relief, most indicated that he handled their case very well."

The male nurse was, and still is, unaware of the covert investigation. The fact that, his supervisor, the key informant, deputy matron, deemed it necessary to carry out the investigation indicated a subconscious attitude, on the part of the key informant, that the male nurse may have been using his profession to charm his female clients.

During the interviews with the key informants, when asked what advantages male nurses have as compared to their female counterparts the 2 of the 5 listed stereotypes rather than actual skills. During the interview with the unit supervisor she said:

"When you are working on night duty, especially in casualty, as a woman, I feel safer having a male nurse around."

The senior nursing officer on her part said:

"Sometimes we have to lift heavy patients or at times heavy equipment. It is an advantage when there is a male nurse on duty because we naturally call upon him for assistance."

The 2 key informants naturally assumed that an added role for the male nurses was providing security and doing the heavy lifting, stereotype roles that men were assumed to fill. The male nurses may have fulfilled the added roles so that their masculinity is not questioned by the female colleagues thus they did the heavy lifting and acted as protectors when called upon by their female colleagues. This was stereotype threat which refers to the expectation(s) that one will be judged or perceived on the basis of a social identity group membership rather than actual job performance and potential. Male nurses are therefore highly likely to experience stereotype threat and be viewed as tokens in the nursing profession.

When the respondents were asked whether they believed that men had an advantage in nursing when compared to female nurses slightly more than half (54.4%) differed with the statement as seen on Table 14. In contrast 29.2% indicated 'Yes', while 12.5% indicated both 'Yes' and 'No'. Those who indicated they did not know were 4.2%.

Table 14:Men have an advantage compared to female nurse Response options Number of male nurses Percentage frequency Yes 14 29.2 No 26 54.2 Both yes and No 6 12.5 I don't know 2 4.2 Total 48 100.0

When the male nurses, who indicated 'Yes', were asked to list some of the advantages most of the respondents indicated aggressiveness and the confidence to undertake more daring and complicated procedures. A respondent who believed that men may have an advantage said:

"I think we are more willing to take on challenging roles especially in fields such as surgical nursing. While the women are just as good as the men are, there is always a slight hesitation to let a man try it first."

The head of department who agreed with the statement that at times male nurses have some advantages over their female colleagues said:

"Clients seem to have greater confidence in male nurses as opposed to the female nurses, sometimes even the female doctors. I have seen patients given prescriptions by female doctors then go on to seek a second opinion from a male nurse."

She further said:

"There are times a patient will ask me a question and you can tell they are not fully convinced by my response. Mind you I am wearing my badge showing my rank. They walk up to a male nurse under my supervision just to confirm whether my response was accurate."

There were those who listed disadvantages when compared to their female colleagues. A respondent working in the minor theatre said:

"When the patients start crying or becoming emotional I have no clue how to assist them. It is challenging dealing with emotional patients I think it is a handicap for most men."

The head of department agreed that there some disadvantages for male nurses said:

"The male nurses are very few, at most each department will be assigned two. Their voice(s) can be drowned out by their female colleagues which means there are times when their opinion may be overlooked, ignored or will not even be heard."

The unit supervisor who also felt there were disadvantages for male nurses said:

"We have communities, due to their culture or religion, who are uncomfortable having male nurses attending to their cases. It is does occurs but very rarely."

Another disadvantage was listed by a respondent who commented that locum, especially those that involved home care, were often more favourable to female nurses.

Table 15: Female nurses have an advantage compared to male nurses Response Options Number of respondents Percentage frequency

Yes 14 29.2

No 28 58.3 I don't know 6 12.5 Total 48 100.0

The respondents were then asked if they believed that female nurses were more suited for nursing. Table 15 above shows that majority of the men (58.3%) indicated they did not believe that women were more suited for the profession. In contrast, 29.2% believed the statement to be true while 12.5% stated they did not know. The deputy matron did not think that female nurses had an advantage as suggested by the statement stated. She said:

"While there are aspects of nursing that require a soft touch that women seem to possess, the profession has evolved over the years from dressers and simple bedside nursing to a complex profession that requires skills in different areas from surgical, maternity, paediatrics, renal, psychiatric, critical care, oncology, endoscopy, theatre, travel nursing etc. The profession needs as many recruits as possible, both men and women and with as diverse backgrounds as the profession demands."

The male nurses' perceptions of advantages and disadvantages they accrued as a result of their minority status highlighted the challenges they faced as a result of their gender. The advantages may have been translated as rewards that motivated male nurses to better perform their duties and for long periods of time. The extra-visibility and stereotypes may however, have resulted in limitations on the male nurses as well as added pressure, higher job strain and higher levels of work stress which negatively impacts on the overall performance by male nurses.

4.5 Performance The fourth objective of the study was to analyse on the job performance of male nurses as caregivers. The respondents were asked to rate their performance by evaluating themselves based on the statements in Table 16 below. The table listed statements that had different skills that male nurses need to effectively perform their role as care givers.

Table 16: Work Habits and Job Efficiency Ratings Rating Statements on work habits and Excellent Above Average( Needs Poor Total (N) rates of efficiency (%) Average( %) Improvem (%) %) ent (%) a. My rate of completing 52.1% 39.9 6.3 2.1 0 100 48 assignments?

b. My ability to work as a team 60.4 29.2 8.4 2.1 0 100 48 member while delivering care? c. My client relations skills? 52.1 37.5 10.5 0 0 100 48

d. My ability to follow health 54.2 37.5 4.2 4.2 0 100 48 care procedures when dealing with patients? e. My ability to handle complex 22.9 59.3 20.8 0 0 100 48 healthcare situations?

f. My organisational and 41.7 43.8 12.5 2.1 0 100 48 planning abilities while doing my work? g. My communication skills? 54.2 35.4 10.4 0 0 100 48

The first statement evaluated the male nurses' rate of completing tasks. This was important because nursing was a very demanding profession which required an individual who was capable of taking responsibility and accountability for the tasks delegated to him. The ability to complete delegated tasks indicated how effective the male nurses were and whether the nurses were able to manage time properly while delivering quality health care. When asked to evaluate their rate of completing tasks slightly more than half of the respondents (52.1%) said they were excellent while 39.9% indicated they were above average. The respondents who indicated they were average were 6.3% while 2.1% of the respondents indicated a need improvement. The results pointed to very encouraging performance of duties by majority of the male nurses.

The second statement evaluated the respondents ability to work as a member of a team. According to the UK's Dept of Health report (2001) it was noted that those working in teams in the health sector had much better mental health than those who worked either in loose groups or individually due to benefits such as better clarity of roles and peer support. WHO safety curriculum states that effective teamwork in health-care delivery can have an immediate and positive impact on patient safety, as such, it is a crucial skill for the nurses not just for the well being of the patients but also their own. The respondents were then asked rate their ability to work as a team member while delivering care. Well over half the respondents (60.4%) indicated they were excellent while 29.2% thought they were above average. About 8.4% rated themselves as average while 4.2% indicated they needed improvement in their team work ability. The results indicate some improvement was necessary for 4.2% of the respondents while a majority painted an encouraging picture in regards to teamwork abilities.

Client relations skills are crucial for service delivery, therefore, the respondents were asked to rate themselves in this regard. Nursing can be frustrating and stressful work. The client relation skills are important so that the nurses are well equipped not to project the stress and frustration of the job on the patients. A majority of the respondents (52.1%) felt they were excellent in client

relation skills while 37.5% indicated they were above average. A bout 10.5% rated themselves as average.

Nursing, as with all medical professions, requires that the personnel are able to strictly follow health care procedures when dealing with patients. According to Ballard (2003) patient safety is an essential and vital component of quality care. As a means to keep patients and health care practitioners safe guidelines spelling out health care procedures have been established. It was vital that nurses are able to strictly follow these set procedures for delivery of safe and quality care. When the respondents were asked to rate themselves a majority (54.2%) indicated they were excellent while 37.5% rated themselves as above average. About 4.2% felt their ability was average and a similar percentage felt they needed improvement. Since medicine is very dynamic, with changes happening often the nurses, should also adopt a lifelong learning attitude to keep up with development of new health care procedures.

According to Hughes (2008) understanding the complexity of the health work is paramount to higher-quality, safer care. It was, therefore, necessary to rate the ability of the nurses to handle the complex procedures and health care situations the male nurses faced in their work. The respondents were asked to rate their ability to handle complex healthcare situations. A majority of the respondents (59.3%) indicated their ability was above average while 29.2% rated themselves as excellent. The rest (20.8%) rated themselves as average. This pointed to an encouraging rate in a majority of the respondents, however, there was need for improvement for those who rated themselves as average.

The respondents were asked to rate their organisational and planning abilities. Booyens (1996) stated that the needs of patients in health care institutions depended upon how planning was done, thus, it was, essential that nurses were able to properly organise and plan for their patient care by efficient time management during the execution of patient care procedures. A majority of the respondents (43.8%) rated themselves as above average while 41.7% rated themselves as excellent. The respondents who rated themselves as average were 12.5%, while one respondent felt he needed improvement. This meant that action was needed to address the nurses who rated

themselves as average and below to improve their abilities to organize and plan their time properly and improve their performance.

The respondents were asked to rate their communications skills which was noted as an essential skill in an effective nurse. The New Zealand Department of Health conducted a survey of nurses and one of the major findings was the significance that nurses placed on effective communication, listing ‘communication with patients’ and ‘communication with other health professionals’ among the top four characteristics of a good hospital (Ng et al. 1992 p.15). When the respondents were asked to rate their communication skills a majority (54.2%) indicated they were excellent while 32.4% indicated they were above average. The respondents who rated themselves as average were 10.5%. Wright (2012) argues that communication skills are essential in building and maintaining a good patient relationship which in turn is key to the treatment and healing process.

When the respondents were asked to approximate how many patients they tend to during their shifts the average number cited was 33 patients, while the mode number of patients was 20 and the median 28 patients. The male nurse who indicated the highest number of patients cited 70 patients while the lowest cited 6 patients. A nurse stationed at paediatric unit indicated that based on his experience being rotated through the different units and departments in the hospital, the number of patients varied from one department to another. He further said that there were departments where one was very likely to have a heavier patient load such as out-patient and MCH. There were departments which were unpredictable such as casualty where for example you may have 2 patients one day and 30 the next day.

The respondents were asked what they found as most challenging when dealing with patients. A majority of the respondents 65% indicated language barrier which complicated communication, 20% listed negative attitude and impatience which resulted in uncooperative patients. One respondent listed triage as a very difficult exercise.

A nurse working in the out-patient unit said

"There are times when you are so overworked that you give patients very limited attention. Patients do not understand the concept of an over worked nurse instead, most expect service with a smile and all the attention possible."

Another respondent said:

"I always find it hard dealing with patients without money or health insurance to cater for the services they require, sometimes urgently. You get caught between administrators who insist on payment for services and empathy for your patients."

Another respondent said:

"The selfish patient who refuses to acknowledge that there are other patients in the waiting room. These are the patients who constantly nag you when you are attending to others because they are very impatient when in the waiting room. This patient wants you to attend to those ahead faster, then when it is their turn they want you to give them undivided attention for as long a time as possible. It can be quite annoying."

Another respondent said:

"The patients who insist on calling nurses 'sister'. It is as if we (male nurses) are invisible."

The respondents were asked if they carried out other duties around the hospital aside from their roles as care givers as seen on Table 17. A majority (77%) indicate they did not while a minority (23%) indicated they had extra duties in the hospital.

Table 17: Whether respondents had any other duties around the hospital Response options Frequency Percent Yes 11 23 No 37 77 Total 48 100.0

Those who indicated they had extra duties listed team leading, teaching, covering the hospital over night shifts, student mentorship, dispensing drugs at the pharmacy and managerial duties. The deputy matron who expressed keen interest in her hospitals maternity unit said:

"I have a male nurse in maternity who has volunteered his time and knowledge to set up a group that mainly teaches young mothers how to care for their babies. The group is well known in the community and the sessions usually well attended."

When the particular respondent was asked about his volunteer work with women he said:

"When the group was started it was a means to address a level of ignorance that existed especially, with new mothers. After they were discharged from the maternity, the new mothers had a lot questions and most used to constantly call me for answers. I decided to start the group to give them a forum where those queries could be addressed and as a result be better equipped as new mothers."

It was worth noting that this particular respondent was among the few who decided he wanted to be a nurse in his childhood years (12 years and under). The respondent also had the added advantage of having two role models in his life at that early age. The performance of the respondent was highly likely to be intrinsically driven. His commitment painted to the possibilities that were inherent in reaching out to young men, in their developmental years, about the opportunities available in nursing.

The respondents were asked how many times they had been absent from work in the previous 30 days. Work attendance record was an indicator in regards to favourable performance. A majority of the respondents (92%) indicated they had not missed work during the previous 30 days. Only 8% respondents admitted that they had missed work. The senior nursing officer felt that male nurses were more flexible with working hours said:

"Male nurse are more flexible with work schedules and less likely to take time off work. Usually when you need a nurse to cover an extra shift I always call on the male nurses. The female nurses, especially those who are married and have families, do not have that

flexibility. The female nurses are also more likely to take time off work to attend to personal or family issues."

The respondents were asked if they had had any form of work related disciplinary action meted against them through e.g. suspension, legal case, reprimand or warning letters etc. This was important since according to ACAS (2006) set disciplinary principles were the means of observing and maintaining set rules and standards. It was a means of addressing any shortcomings in the conduct and/ or performance of an employee as well as a means to enhance effectiveness within the organisation. A majority, 97.1%, of the nurses indicated they had not been subject to any disciplinary procedures. While it was expected that the respondents may have been less than forth coming with such information, the key informants largely corroborated this view. The key informants indicated they had not had any formal disciplinary action against any of the male nurses working under them.

Table18: Respondents subject to work related disciplinary action Response options Frequency Percent Yes 1 2.1 No 47 97.9 Total 48 100.0

The respondent who had been subject to disciplinary action indicated he had been given a few oral warnings which then culminated in a warning letter after being absent from work on several occasions. The respondents acknowledged that the disciplinary action had a positive impact on his performance since he had since improved his attendance.

The respondent were then asked whether they had been the subject of formal complaint(s) from patients as result of their work. A majority of the respondents (97.9%) indicated they had not been subject to a formal complaint. Only a single respondent acknowledged being subject to a formal complaint.

Table 19: Respondent subject to a formal complaint Response options Frequency Percent Yes 1 2.1 No 47 97.9

Total 48 100.0

He said:

"I was implicated by a con-woman in her scheme to steal from a patient in the hospital. The patient filed a formal complaint indicating that I was working in cahoots with the woman. I was later cleared but it took time to restore my reputation"

The respondents were asked to rate their most recent performance review as seen on Table 20. A majority of the respondents, 83.3%, indicated they rated it as either very positive or positive. About 12.5% indicated they were neutral while, 4.2% said they did not know.

Table 20: How the respondents rate their performance reviews

Rate of the review Frequency Percent Very positive 16 33.3 Positive 24 50.0

Neutral 6 12.5

I don't know 2 4.2 Total 48 100.0

The respondents were asked whether they thought the performance reviews were a reflection of their performance as seen on Table 21. A majority of the respondents (68.8%) concurred with the findings of the performance reviews. While, 22.9% of the respondents held a contrary opinion and 8.3% of the respondents indicated they did not know.

Table 21: Whether respondents agreed with their performance reviews Response options Frequency Percent Yes 33 68.8 No 11 22.9 I don't know 4 8.3 Total 48 100.0

A respondent who said the performance review did not reflect actual performance said:

"At times the senior managers already know what they want reflected on the reviews so its reduced to just a public relations exercise"

A key informant said:

"The reviews are important because they allow us to assess the weaknesses and strength of the staff in our departments. As a supervisor I wish the outcomes of the reviews we taken a lot more seriously. As it is, we mostly shelf the findings from the exercise."

Most of the respondents who did not agree with the reviews listed bias and lack of objectivity on the part of their supervisors. During the study it was noted that most nurses were skeptical of the reviews. When asked why this was the prevalent situation one the respondents said:

"The performance reviews are a good indicator of the work being done by the nurses. However, the reviews rarely take note of our concerns especially since most of us are overworked and underpaid. The reviews may reflect how well you are working but since it does not lead to an improved working environment most us see them as mere formalities."

The respondents were asked to rate their performance in regard to a series of statements on confidence, job strain and job satisfaction. This was important to analyse the perspective held by the male nurses in regard to their ability to handle their role as caregivers and manage the stress that came with the job.

Table 22:Respondents evaluation of their abilities Statements on abilities Very High No Opinion Low Very Total (N) High (%) (%) (%) Low (%) (%) (%) a. The level of confidence in 50.0 37.5 8.3 4.2 0 100 48 my competence as a nurse? b. I find nursing very straining 12.5 27.1 22.9 27.1 10.4 100 48 and stressful. c. My level of job satisfaction 8.3 20.8 20.8 25.0 25.0 100 48

The respondents were asked to rate the confidence they had in their competence. A majority of the respondents (87.5%) had high levels of confidence in their competence. What was worth noting was that 4.2% of the respondents had a low confidence on their competence which indicates a need to retraining or further training to boost confidence levels. The rest of the respondents (8.3%) of the respondents indicated they had no opinion.

The respondents were asked to state the level of stress and strain they experienced as a result of their work as nurses. A majority of the respondents (39.6%) indicated either very high or high level of stress and strain while a slightly lower number (37.5%) indicated either very low or low levels of stress and strain. The rest of the respondents (22.9%) indicated they had no opinion. The findings established that quite a number of the nurses regarded the profession as strenuous and stressful.

The head of department noted that stress was a part of the job since nursing is a very demanding career. She indicated that the stress resulted in an added challenge which was dealing with substance abuse among the nurses, especially the male nurses who were more likely to abuse prescription drugs and alcohol. She said:

"I have noted over the years that some of the nurses, especially the theatre nurses and surgical nurses, abuse prescription drugs as a means of dealing with the stress. Morphine and pethidine are the most notable

pharmaceutical drugs abused and like the rest of society alcohol abuse is also a problem."

The unit supervisor also cited a case of a male nurse in her hospital, who had resumed work after a stint at an drug rehabilitation facility. She added that the nurse was a noted alcoholic and that it was his second spell at a rehabilitation facility. The senior nursing officer also added that she had noted over her long career and working in different health facilities that male nurses were more likely to experiment with the prescription drugs compared to the female counterparts. She said:

"We closely monitor all the nurses but from past experiences the male nurses will always find a loop hole and experiment with some of the restricted drugs."

Trinkoff, A. M., and Storr (1998) in their study found that some nursing specialties, such as anesthesia, critical care, oncology, and psychiatry, are prone to higher levels of substance abuse because of intense emotional and physical demands and/or due to the availability of controlled substances in these areas.

The respondents were asked to state the level of job satisfaction they felt in regards to their role as care givers. Half of the respondents (50%) had either a very low or low levels of job satisfaction while in contrast 29.1% had either very high or high levels of job satisfaction. This meant that a majority of the respondents were unsatisfied with the job which may have caused low levels of performance and compromising the quality of health care.

The respondents were asked whether they had been nominated and/or had received any award(s) and/or commendation(s) e.g. employee of the month, nursing excellence award etc. as a result of their work. Awards were a sign on the part of the respondents' ability and recognition for delivering exemplary service to the clients.

Table 23: Respondents with awards Response options Frequency Percent Yes 9 18.8

No 39 81.3 Total 48 100.0

A majority of the nurses indicated they had not received any award(s) and/or been nominated for an award(s). Most notably, 18.8% of the respondents confirmed that they had received an award(s). The respondents nurses who confirmed being recipients of an award had listed being nominated or receiving the award for either nurse of the year or nurse of month award. A respondent who had received awards said:

"I have been awarded the nurse of the month in the maternity unit. A few years ago I also received the nurse of the year award in Wajir District."

The director of nursing services said that one of her male nurses had declined nomination for nurse of the year award. She said:

"He told me that he did care for the award. He told me to let him serve his patients in peace. The award was of very little significance to him."

This was a unique case since most of the nurses indicated they all wanted to receive commendation as a result of their work. I posed the situation to the responds and asked them what were their thoughts on the male nurse who had refused a nomination for an award. Most of the respondents were in agreement that this unique and atypical but had no possible explanation. A respondent commented and said:

"Commendation was not only validation of my competence but a boost on my resume. I do not know why anyone, male or female, would turn down the opportunity for an award."

A nurse who had 6- 10 years experience, who had a plausible explanation, said:

"There are those who have never accepted the work we do for a living, privately and publicly. An award is a public admission of your role as a nurse. I think it is a combination of denial and male ego."

Awards were not only incentives in recognition of workers' excellent service but they were also indicators of performance of the employees. The fact that a some of the male nurses were had either been recipients of the awards or had been nominated for an award indicated exceptional service from male nurses.

4.6 Coping mechanisms The fifth objective was important to identify the various ways employed by the male nurses to deal with working in an environment where they were the minority. Table 24 below outlined a series of statements that presented different scenarios and experiences that the respondents may have confronted in their profession. The statements were a way to evaluate the coping mechanisms of the male nurses.

Table 24:Coping mechanisms of male nurses Statements on coping mechanisms Very often Often Not Never Total( (N) (%) (%) Often(%) (%) %) a. Felt insecure and ashamed about your 2 2 56 40 100 48 occupation? b. Questioned whether you are a “real man” 0 0 19 81 100 48 because of your work as a nurse. c. Indicated that you work at a hospital but did not 4 17 40 40 100 48 actually reveal your specific position or job to other people? d. Have to give reasons for being a male nurse to 2 8 40 42 100 48 other people when asked what you do for a living? e. Modified and or lied about the title of your job 6 8 31 54 100 48 when asked what you do for a living? f. Emphasised the complex roles and 4 29 48 19 100 48 responsibilities aspects, parts, or tasks of your job when talking about it to others? g. Have formed and/ or is part of a social group 6 4 10 80 100 48 just for male nurses at my place of work? k. Women co-workers treat you better than they 13 19 40 29 100 48 do other women workers because you are a man?

l. Women bosses/supervisors treat you better 8 6 52 33 100 48 than they do women workers because you are male? m. Male co-workers treat you better than they 8 13 44 35 100 48 do women workers because you are a man? n. Male bosses/supervisors treat you better than 4 8 38 50 100 48 they do women workers because you are a man? i. A patient declined your services because you 0 0 35 64 100 48 were a man? j. A patient preferred your services because you 27 38 23 13 100 48 were a man?

The first statement sought to establish whether the respondents succumbed to social stereotypes in regards to their profession. When society constantly holds the view that your profession is reserved for women one is likely to feel embarrassed and/or ashamed and/or psychologically insecure. Majority of the respondents, 56%, indicated they had, but not often. In contrast 40% indicated they had never felt that way about their career. 2% of the respondents indicated that they felt that way very often while another 2% said they felt it often. This indicates that quite a number of the male nurses were still having a hard time adjusting psychologically to their role as male caregivers possibly due to the prevalent stereotype that nursing was a woman's job.

Statement 2 explored whether the male nurse had been questioned whether they were 'real men' as a result of their work. The perception that a man was doing a woman's job was likely to lead to questions in regards to the masculinity of the male nurses. A majority of the respondents (81%) indicated they had never been questioned whether they were 'real men' because of their work as nurses. In contrast, a minority 19% indicated their masculinity had been questioned but not very often. This indicates that male nurses, though not often, still experienced gender barriers which were tied to the societal construct of masculinity as a result of their career choice.

Statement 3 looked into work place specification by the male nurses. This looked into whether the respondents had ever been asked where they worked but chose to name the hospital but did not actually reveal the specific position or job to other people. About 40% of the respondents indicated they had never done that. In contrast, 40% of the respondents indicated they had but not often, 17% had done so often and 4% very often. The findings of this study showed similarity

with Smith (2008) who also noted that some of the men who worked in female-dominated careers tended to associate themselves with their places of work rather than their specific job.

Statement 4 looked into role justification by the male nurses. This explored how often the respondents had experienced situations where they had to justify why they were male nurses when asked what they did for a living. A number of the respondents (40%) indicated they had but not often, while 19% had done it either very often or often. A little under half of the respondents (42%) had never had to justify their career.

Statement 5 analysed relabeling by the respondents. The respondents were asked whether they had modified and or lied about the title of their job when asked what they did for a living. Majority of the respondents (54%) stated they had never had such an experience. About 31% of the respondents indicated that they had experienced such a situation but not often, while 15% had either experienced it very often or often. According to Simpson (2004) men in female-dominated occupations tend to re-label their jobs as a means of enhancing their status.

During the study it became apparent that male nurses were constantly confused by the patients as the doctors mainly due to their similar dress code i.e. official clothes and a white lab coat. During the interviews, in all of the health facilities none of the male nurses who were addressed as daktari made any effort to correct the patient. The senior nursing officer who felt that the dress code for male nurses allowed a degree of flexibility said:

"The male nurses' dress code is not as strict as with the female who have a defined uniform. The dress code allows a certain degree of flexibility for the men. It is therefore very common for them to be confused with the doctors. In fact all the male nurses are 'daktari' to the patients while the female nurses, irrespective of job rank, are 'sister'."

A nurse who was in 40-44 years age bracket, and had 11-15 years experience provided additional information. He said:

"I was at a medical conference and I remember standing up to ask the panelists a question, I said my name and the hospital I came from but I did

not specify I was a nurse. The panelist referred to me as daktari as he answered my question. I did not correct him or clarify my specific my role was nursing. It was one of the few occasions I have let people assume my profession."

While the male nurses' daktari identity is as a result of the assumptions made by others, the fact that the assumptions were not corrected implies complicity on the part of some of the male nurses in projecting a false identity.

Statement 6 analysed role specification by the male nurses. The respondents were asked whether when they talked to other people about their jobs they lay emphasis on the complex aspects of their roles and responsibilities. A majority of the respondents (48%) indicated they had but not very often, while 33% had done so either very often or often. In contrast a minority (19%) of the respondents indicated they had never done so. Role specification was another means of enhancing the status of a role one deemed less prestigious

Statement 7 analysed whether the male nurses had formed social groups in their places of work. The social groups were observed as a way of dealing with working in a field dominated by women. According to the findings of the study conducted by Warming (2005) the male groups that exclude their female colleagues were often established as an alternative to the female- dominated environment. A majority of the respondents (80%) indicated they had never formed or been part of the such a group, about 10% said they had but not often while 10% of the respondents indicated either very often or often. During the study it was observed that the limited number of male nurses in the hospitals meant that each department was allocated utmost two nurses at a time. This limited the male nurses from having a common forum that may have lead to the development of social groups similar as noted by Warming (2005). Statement 8 analysed whether the male nurses were treated better by their female co-workers as compared to how the women treated each other simply because of their gender. A majority of the respondents (40%) indicated that they were treated better but not often, while 32% said it happened either very often or often. About 29% of the respondents, however, indicated they had

never experienced preferential treatment from their female colleagues. The head of department felt that conflicts were more likely to occur between female nurses. She said:

"Conflicts are common between the female nurses but they rarely involve the male nurses versus the female nurses.”

Statement 9 analysed whether the female bosses/supervisors treated the male nurses favourably compared to the female nurses. Majority of the respondents (52%) indicated that they were treated favourably by their female supervisors but not often, while 14% indicated it happened either very often or often. In contrast, 33% of the respondents indicated that they had never experienced preferential treatment from their female bosses. The Senior Nursing officer admitted that at times she preferred to deal with the male nurses as compared to the female nurses. She said:

"I am a mother of three boys and I think as a result of raising them and dealing with them for so long I have found it is easier to reason with men. I think that my experience may explain my preference in dealing with the male nurses under my supervision."

Statement 10 sought to analyse whether the male nurses were treated better by their male colleagues because of their gender. A majority of the respondents (44%) indicated that it was the case sometimes but occasionally, while 21% indicated that it happened either very often or often. In contrast, 35% of the respondents indicated they had never experienced preferential treatment from their male colleagues based on their gender.

Statement 11 sought to analyse whether male bosses/supervisors treated the respondents better than they did their female colleagues. A majority of the respondents (50%) indicated they had never experienced any preferential treatment, while 38% of the respondents indicated that it was an occasional occurrence and about 12% indicated it occurred either very often or often.

Statement 12 sought to establish whether a patient had ever declined to be served by the male nurse due to his gender. A majority of the respondents (64%) indicated that had never had an

experience where a patient declined their service. The rest (35%) indicated it had happened but very rarely. A key informants recalled her experiences a unit supervisor of the maternity and said:

"There are certain communities with very strong preference for female personnel handling the cases involving female patients. We try to identify them early enough so that we do not expose our male nurses to discriminatory treatment and while also respecting the preferences of the patients."

Discrimination against the male nurses did occur occasionally. However, it was the discrimination against female nurses that seemed more pronounced especially by patients in the maternity. Gender discrimination was observed as prevalent in some of the departments and this was a cause for concern for the relevant authorities in charge since it may result in a demoralised work force both male and female.

Statement 13 analysed whether the male nurses had experienced situations where a patient preferred their services because of their gender. A majority of the respondents (65%) indicated they had experienced it either very often or often, while 23% had experienced it but not often. In contrast only 13% of the respondents indicated that they had never experienced it. Most of the key informants held the view that the preference for male nurses was very common in the maternity wards. The senior nursing officer agreed with the statement. She said:

"Male nurses are very popular with most patients. They are diligent with their duties and are known to handle patients with care especially those assigned to the maternity ward and MCH."

The deputy matron also agreed with the statement and highlighted an outstanding male nurse in her maternity unit:

"I have a male nurses who has done 77 deliveries in the past 3 months compared to the female colleague with the highest number of deliveries, which is about 40."

Gender seemed to hold sway not only with the staff at the hospitals but also with the some of the patients.

Lastly the respondents were asked open-ended question on why they thought there were few men in the profession. A majority of the respondents (63%) cited that the myth that nursing is a preserve for women was prevalent. Some of the respondents indicated that the few role models and the unclear history about the contributions made by men in nursing significantly built up the myth. Some of the respondents indicated that while bedside nursing was part of the profession, it was not the only job description. However bed side nursing led to the prevailing tag of 'dirty job', which had proved hard to change leading to the low opinion most young people had of the profession.

The nurses were also asked to give recommendations of possible ways of encouraging more young men to venture into nursing. About 42% of the respondents indicated raising public awareness and increasing the level of information available to the public in regards to the opportunities available in nursing. The senior nursing officer indicated that she previously worked as a lecturer in one of the nursing schools. She said:

"When I was a Lecturer we used to go to mixed and girls secondary schools for career talks. There should be increased career symposiums targeting boys high schools."

About 19% of the respondents stated that improving the remuneration package was the best place to start. A respondents who supported better remuneration said:

"A well paying job will always attract the best and brightest. I think when the pay package is commensurate with the work the there will be an influx of young people especially, men, into the profession."

Another respondents suggested introduction of quotas for the enrollment of young men into nursing schools. This would be a means to compel institutions to increase the enrollment numbers of young men. Some of the respondents also listed increased slots for young men in nursing colleges and/or universities.

Another respondent who had studied abroad said that the American Nursing Association had put up advertisements specifically targeting men to increase their interest in nursing as a career. He suggested the same approach be adopted in Kenya.

4.6 Conclusion In conclusion the analysis of the performance of the male nurses painted an encouraging picture on the skills and abilities the male nurses had. However, it was noted that there was need for retraining and or further training for those who were average and below. It was also evident that the minority status of male nurses had an impact on their perceptions of their career which shaped some of their attitudes and was likely to impact their performance. The concerns raised on the extrinsic rewards should be addressed to motivate the nurses to better perform their duties. Finally the myths built around nursing as a female job should be addressed to encourage more young men to venture into the profession as it was evident that having male nurses was a clear advantage for all the health facilities.

CHAPTER FIVE: SUMMARY, CONCLUSIONS AND RECOMMENDATIONS

5.1 Introduction This chapter gave a brief summary of the main findings, conclusions on the study and made recommendations.

5.2 Summary

The overall purpose of this study was to assess the role of men as caregivers, by focusing on their motivations for entry into the career, the rewards they perceive important to have a successful career, their perception of their career, their job performance and the coping mechanisms they have adopted.

5.2.1 Motivations for entry into the career

The study found that based on the categorization by Williams(1992) and Simpson (2004) a majority of the respondents were finders which meant that they ventured into nursing accidentally as they made general career decisions. Seekers, who were slightly fewer, actively sought a career in nursing while a minority, settlers, had either tried their hand at other professions and /or had gone through a period of unemployment. The distribution between the three categories demonstrated that the respondents balanced between intrinsic and extrinsic motivations.

The study found that only 30% of the respondents benefited from having role models who motivated their entry into nursing. O’Lynn (2004) who studied the gender-based barriers faced by male student nurses noted that lack of role models for the men was a major barrier. This was also a possible reason why so few of the respondents had little or no admiration for nurses before venturing into the profession. Role models past and present were noted as a positive catalyst for more men venturing into nursing. Documenting the historical contribution of men in nursing was a possible avenue to identify male icons in nursing to act as role models.

The study found that only 6.3% of the respondents wanted to be nurses when they were in their childhood (12 years and under). This indicated that very few boys saw nursing as a possible career path. This was in stark contrast to 80% of the female key informants who indicated they knew they wanted to be nurses in their childhood. Miller and Budd (1999) noted that girls were learning from an early age to have a more liberal approach to their career choices as opposed to the boys who, like Morris, Nelson et al. (1999) point out, were far less likely to consider nontraditional careers. This indicated that, the socially accepted laxity towards empowering the boy child needs to be addressed so that socially constructed myths, such as certain careers maybe too feminine hence unsuitable for men and/or a preserve for women, were addressed and possibly debunked.

The study also found that majority of the male nurses (45.8%) entered the profession without sufficient information on the opportunities for men in nursing. It was, however, encouraging that 92% of the respondents perceived the attitude of their parent(s) as supportive.

It was clear that a lot more information needed to be disseminated to young men and boys at an early age so that a greater number would make the career choice as early as childhood. More importantly, highlight the historical contribution of male nurses so that role models were identified and a higher level of admiration for nursing with young boys would be nurtured.

5.2.2 Rewards

The study found that majority of the respondents balanced between intrinsic and extrinsic rewards. While it was noted that, quite a number of the respondents valued intrinsic rewards derived from being a male nurse extrinsic rewards were also noted as equally important. However, a majority of the respondents took exception to the remuneration package they received. This was likely to demoralise the male nurses as they played their role of care givers.

As was noted by Agezegn et al. (2014) in their study in the Sidama zone public health facilities, South Ethiopia, nurses who were dissatisfied at work, distanced themselves from patients and neglected their nursing responsibilities, which translated into poor quality of care. Dissatisfaction of the male nurses on the extrinsic rewards they received may have been one of the indicators as to why few publicly took pride in their work, it may also have resulted in poor job performance, lower productivity, and staff turnover which was ultimately very costly to health care facilities and highly likely to compromise the quality of health care.

5.2.3 Perceptions the male nurses had of their profession

The study found that as a result of their minority status most male nurses felt they had heightened visibility at work which was likely to result in added pressure and experience stereotype threat because of their perceived token status. A number of the nurses indicated that they were subject to stereotypes, though, in most cases, not very often. This was likely to create an unfriendly working environment where the nurses were judged first by their gender rather than by their execution of duties. It was noted that the male nurses were expected to fulfill additional roles that men were socially expected to fulfill even though, it was not part of their job description. This was likely to influence the performance of the male nurses in the long term. It was noted as necessary to create a gender sensitive work environment for the male nurses.

On a positive note, majority of the respondents (54.2%) indicated they did not believe that men had any advantage when compared to their female counterparts. An almost similar number of the respondents (58.3%) also indicated that they did not believe that women were more suited for nursing than men. This indicated that the male nurses viewed the nursing as career just like any other. Emphasis should be made on further understanding the perceived challenges men faced to better address some of the negative aspects of being a male nurse.

5.2.4 Performance

The study found that most of the respondents were confident in their abilities to comfortably execute duties. However, a number indicated they were either average and/or needed

improvement in some areas such as communication skills, organisation and planning skills, and ability to handle complex health situations. This indicated a need for further training or retraining to build confidence and refresh the knowledge of the particular respondents.

The study also found that 63.3% of the respondents found their performance reviews as either very positive or positive. However, most of the respondents were skeptical of the impact of the reviews since working conditions did not improve and/or change after the reviews. This was likely to contribute to job dissatisfaction compromising the performance of the nurses.

About 2.1% of the respondents reported to have been subject to disciplinary action while a similar percentage were subject to a formal complaint from a patient. It was, none the less, important to note that 97.9% of the respondents had no disciplinary cases or formal complaints which painted a picture of a mostly effective and disciplined male workforce. On an even more positive note, 18.8% of the respondents had either been nominated for or were recipients of an award(s) due to their exemplary job performance.

The key informants alluded to a pattern of substance abuse by some of the male nurses whether it was a result of the stress and strain that characterises the nursing profession or due to the easy access to pharmaceutical drugs or a combination of both may require further inquiry. Therefore, a level of importance should be given towards finding ways of equipping nurses with a variety of strain and stress management strategies to prevent burnt out by the nurses and maintain quality care for patients.

5.2.5 Coping mechanisms

It was noted during the study that due to the obscure dress code most of the male nurses were confused with the doctors by the patients which resulted in the assumed persona of daktari that a majority of the nurses never bothered to correct. This projection of a false image by the male nurses may require further examination to identify the motivation behind it. A false image may have been a coping mechanism adopted by some of the nurses to elevate their perceived status

with their patients. It may also be an indicator of a low opinion held by some of the male nurses in regard to their profession or an identity crisis faced by male nurses.

The study noted that the nurses both male and female faced a level of discrimination at work from both the staff and at times the patients. This pointed to a need for the introduction of gender mainstreaming in nursing to create a lot more sensitization on gender barriers that resulted from gender discrimination. As professionally trained nurses both male and female staff should enjoy similar advantages and disadvantages that came with the profession.

Lastly, the respondents were asked two open-ended questions on why they thought there were low numbers of young men interested in joining the profession and secondly possible solutions to remedy the situation. The Majority cited the myth that nursing was a female career and the poor pay as the result many young men had no interest in the profession. On the possible remedies, most suggested increased information available to the public on the various opportunities available for men in nursing. Some of the respondents suggested that an improved remuneration package would attract the best and brightest to the career irrespective of gender.

5.3 Conclusions

The study concluded that there was growing diversity within the health profession that required all hands on deck. The shortage within the health care sector was not a Kenyan problem but rather a global crisis. The training of young men and women in nursing and other health care professions in Kenya, can greatly help plug the shortage in the field, and improve the delivery of quality care to all. The export of the surplus labour to the rest of Africa may provide an avenue of addressing the high unemployment rates in the country. However, there was need for action to be taken on possible avenues to inspire more young people, more so young men, to view nursing as a possible career.

5.4 Recommendations Policy

1. There is need to review the enrollment policies for colleges and universities to increase the number of young men enrolling for nursing related courses. 2. There is need to develop policies that introduced gender mainstreaming to the nursing profession. This would make the profession have a more conducive and inclusive working environment for both men and women.

Program 1. There is need to develop programs that targeted boys in their early age to introduce them to nursing, as well as, other female-dominated careers, to promote these careers and show them the available opportunities. 2. There was need to establish male-only awards as a means to highlight the performance of the male nurses. Male nurses' award may also highlight the contributions of the men and highlight their existence to a society oblivious to their presence.

Research 1. There is need to conduct more research on the experiences of men working in female- dominated professions and the different psychological aspects of how the men deal with the predominantly female working environments. 2. There is need to conduct research on the history men of nursing in Kenya and globally. This may highlight the contributions made by men over the years in the profession. The historical account of the place men hold in nursing may identify sufficient role models for men in the profession. 3. The is need to conduct research on the claims by the key informants that some of the nurses may be resorting to substance abuse either because it is as a means of dealing with the stressful environment of nursing or due to easy access.

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LIST OF APPENDICES

APPENDIX A: PARTICIPANT INFORMATION

Participant’s number. ______Hospital ______

Investigator Mr. Walter Thuku Kamau Contact Details: Po Box 123-00200, Nairobi. Cell: 0716534844 Email: [email protected]

Investigator statement My name as stated above is Walter Thuku Kamau. I am conducting a research study titled: Male nurses as caregivers: a study on the performance of male nurses in selected Public health care facilities in Kiambu County. I will now give you information on what the assessment is about. Afterwards, I will invite you to be a study participant. Once I have shared this information, you can decide whether or not you will participate in the study. Please feel free to stop me as we go through the information and I will take time to explain any queries or concerns you may have. If you have questions afterwards, you can ask me so I can respond to your concern or query. This process is called 'informed consent'. I will give you a copy of this form for your records.

May I continue? YES / NO ______This study has an ERC approval ______

Introduction and procedure The overall purpose of the study is to examine the performance of male nurses in a profession that is perceived to demand qualities that are traditionally associated with women for the purpose of generating information that would be helpful in designing policies and/or campaigns aimed at encouraging more men to venture into nursing, and possibly, other female-dominated professions as well. The researcher listed above is interviewing registered male nurses working in selected public health facilities. The purpose of this interview is to gather data on the performance of male nurses as care givers. Participants in this research study will be asked questions about their motivations for entry into nursing, the rewards they receive, their perceptions of their role, their coping mechanisms and their general performance as nurses. There will be approximately 60 participants in this study some randomly chosen and others purposively selected. We are asking for your consent to consider participating in this study.

Benefits The information you provide will help provide a better understanding of the gendered labour market from the unique perspective of men as the minority. Nursing is a career perceived to be a preserve for women and your contribution in this study may assist in dispelling these assumptions. The information you provide will also be a contribution to social science and may influence policies and/ or campaigns aimed at empowering male youth and increased interest of men in nursing and other female-dominated careers.

Risks No direct or indirect risks are anticipated in the study. Only your precious time will be taken by the interviewer.

Confidentiality All the information you give will be treated with utmost confidence and information to identify you will not be released to any person or forum without your permission.

Voluntariness Your decision to participate in research is voluntary. You are free to decline participation in the study and you can withdraw from the study at any time without injustice or loss of any benefits.

APPENDIX B: CONSENT FORM Investigator Mr. Walter Thuku Kamau

Contact Details: Po Box 123-00200, Nairobi. Cell: 0716534844 Email: [email protected]

Participant’s statement I have read this participant’s information and consent form. I have also had my questions concerns addressed in a language that I understand. I understand that my participation in this study is voluntary and that I may choose to withdraw any time. I freely agree to participate in this research study. By signing this consent form, I have not given up any of the legal rights that I have as a participant in a research study.

I agree to participate in this research study: Yes______No _____

Participant’s number: ______Date ______

Participant signature / Thumb stamp ______

Researcher’s statement I have fully explained the important details of this research study to the participant and believe that the participant has understood and has freely given his/her consent.

Researcher‘s Name: ______Date: ______

Signature of Researcher: ______

APPENDIX C – RESEARCH INSTRUMENT

Participant’s serial no.:______

Name of the health care facility you currently working in?

Personal Characteristics a) Age group? i) 24 and Below ii) 25-29 iii) 30-34 iv) 35-39 v) 40-44 vi) 45-49 vii) 50-54 viii) 55 and above b) What is your marital status? a. Single b. Married c. Divorced/ Separated d. Widower c) What is the highest level of education you have attained? (If still enrolled please tick the previous grade) a. Secondary b. College Diploma______c. University(specify)______d. Post-graduate (Specify)______d) How many years have you been a registered nurse? i) 0-1 ii) 2-5 iii) 6-10 iv) 11-15 v) Over 15 years

e) Which pre and post-service professional training have you received? Please list in the table

NAME OF INSTITUTION TITTLE OF THE FROM TO WHO FINANCED e.g. PROFESSIONAL MO/YEAR MO/YEAR Self, Employer, Govt., COURSE NGO etc.

g) Please write all previous positions within nursing that you have held (if applicable)?

NAME OF HEALTH LOCATION FROM TO AREA OF SPECIALTY INSTITUTION MO/YEAR MO/YEAR

Section I – Motivations for entry into nursing 1. About what time period or age did you decide you wanted to be a nurse? a. Childhood (12 years old and younger) b. Teenage years (13-19 years old) c. Young Adult (20-29 years old) d. Middle Age (30-39 years old) e. Old Age (40 years old and older)

2. Before you entered the nursing profession, were you aware of the opportunities available for men in nursing? a. Yes b. No c. I don’t remember

3. Please select the statement (or statements) that best represent how you entered the nursing career? a. Attended a career seminar/program for nurses b. Influenced by a role model. c. Came to nursing after K.C.S.E exam results. d. Came to nursing after trying other jobs. e. Came to nursing after a period of unemployment f. Other ………………….

4. Which of the statements best represents the factor (or factors, where applicable) which motivated you to venture into nursing?

Agree Strongly Neutral Disagree Strongly Statement Agree Disagree a. I had a passion for helping people and nursing was the best way. 1 2 3 4 5 b. I admired nurses. 1 2 3 4 5 c. I was influenced by a role model. 1 2 3 4 5 d. Nursing offered good employment benefits and opportunities for men. 1 2 3 4 5 e. I chose nursing because that is what my 1 2 3 4 5 K.C.S.E grades qualified me for.

5. I) What was the attitude of your mother and/ or father to your career choice? a) Supportive b) Not supportive

c) Indifferent d) Disappointed e) I don’t know

II) Did that affect or influence your decision to enter into nusring? a) No b) Yes

Please explain why?

Section II - Rewards 6. Does the care giving role of nursing fit in with your character? a) No b) Yes

Please explain why?

7. Approximately how much do you earn per month?

a) Below 10000 b) 11000-20000 c) 21000-30000 d) 31000-40000 e) 41000- 50000 f) 51000 and above

8. What other benefits and/ or allowances do you receive?

9. Have you received a promotion since you started working in nursing? a. Yes b. No c. Not applicable

If yes, please list the promotions

If No, please state why? ______10. Would you say that the current conditions of work in terms of salary, benefits and allowances are? a. Very satisfactory

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b. Satisfactory c. Neutral (neither satisfactory nor unsatisfactory) d. Un-satisfactory e. Very un-satisfactory f. Do not know

11. What other additional benefits and/ or rewards do you think would improve the performance of nurses?

Section III - Male nurses’ perception of their profession 12. Please circle how much you agree or disagree with the following statements.

Strongly Agree Neutral Disagree Strongly Agree Disagree a. Male nurses are more visible than female nurses. 1 2 3 4 5 b. I feel pressure from within myself to move to a higher position within nursing 1 2 3 4 5 c. Supervisors and/or bosses put pressure on me to move to a higher position within nursing. 1 2 3 4 5 d. Family members and friends put pressure on me to move to a higher position within nursing. 1 2 3 4 5 e. Male nurses tend to be promoted faster and to higher positions than female nurses. 1 2 3 4 5 f. Male nurses tend to be considered for promotion and advancement more often than female nurses. 1 2 3 4 5

13. There are negative perceptions commonly associated with men in nursing in the literature and media. The next questions will explain some of the stereotypes and ask you how often you have encountered each of them. a. The perception that male nurses are too feminine and some people assume you are less masculine because you are a man in nursing. How often have you encountered this stereotype within the last year? a. Very often b. Somewhat often c. Not very often d. Never

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b. The perception of “easy job” is when other people assume that you could not fit into a more mainstream traditionally and more demanding male occupation and must be in nursing because it is easy, safe and less demanding. How often have you encountered this stereotype within the last year? a. Very often b. Somewhat often c. Not very often d. Never c. The perception of “womaniser” is when people assume that you are in the nursing profession because you are drawn to the possibilities of contact will a lot of female colleagues and patients with the goal of dating and/or sexually objectifying them. How often have you encountered this stereotype within the last year? a. Very often b. Somewhat often c. Not very often d. Never

14. Do you believe men have an advantage in nursing as compared to female nurses? a. Yes b. No c. Both yes and no d. I don’t know If yes, please list some of the advantages? ______

If no, please list some of the disadvantage? ______

15. Do you believe that women are more suited for nursing than men? a. Yes b. No c. I don’t know

If yes or no, please state why? ______

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Section IV- Performance 16. Please rate your performance by circling the appropriate number. (Excellent = 1; Above Average = 2; Average = 3; Needs Improvement = 4; Poor = 5) 1. Work Habits and Job Efficiency Ratings

Statement Rating 1 2 3 4 5 a. My rate of completing assignments?

1 2 3 4 5 b. My ability to work as a team member while delivering care?

1 2 3 4 5 c. My client relations skills?

1 2 3 4 5 d. My ability to follow health care procedures when dealing with patients? 1 2 3 4 5 e. My ability to handle complex healthcare situations?

1 2 3 4 5 f. My ability to manage stressful situation?

1 2 3 4 5 g. My organisational and planning abilities while doing my work?

1 2 3 4 5 h. My communication skills?

17. Approximately how many patients do you see in a day?

18. What do you find most challenging when dealing with patients?

19. Are there any other duties that you do around the hospital? a. Yes b. No If yes, please briefly list the other duties? ______

20. How many times were you absent from work in the last 30 days?

21. Have you had any form of work related disciplinary action against you e.g. suspension, legal case, reprimand etc.? a. Yes b. No

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c. I don’t know If yes, please briefly explain why? ______

22. Have you had any formal complaints from patients as a result of your work? a. Yes b. No c. I don’t know If yes, please briefly explain why? ______

23. How would you rate your most recent performance review at your current work place? a) Very positive b) Positive c) Neutral d) Negative e) Very negative f) I do not know

24. Do you think the reviews are a reflection of your performance? a. Yes b. No c. I don’t know

If yes or no, please state why? ______

25. Please circle the level that you think most applies to you from the following statements.

Very High No Very Statement Low High Opinion Low a. The level of confidence in my competence as a nurse? 1 2 3 4 5 b. I find nursing very straining and stressful. 1 2 3 4 5 c. My level of job satisfaction 1 2 3 4 5

26. Have you ever been nominated or have you received any award(s) and/ or commendation(s) e.g. employee of the month, nursing excellence award etc. as a result of your work? a. Yes b. No If yes, please state which award(s) you have received or been nominated for?

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Section V -Coping mechanisms 27. Please circle how often you have experienced the following situations?

Statement Very Often Not Never often Often a. Felt insecure, ashamed, or embarrassed about 1 2 3 4 your occupation? b. Questioned whether you are a “real man” because of your work as a nurse. 1 2 3 4 c. Indicated that you work at a hospital but did not 1 2 3 4 actually reveal your specific position or job to other people? d. Have to give reasons for being a male nurse to other people 1 2 3 4 when asked what you do for a living? e. Modified and or lied about the tittle of your job when asked 1 2 3 4 what you do for a living? f. Emphasised the complex roles and responsibilities aspects, 1 2 3 4 parts, or tasks of your job when talking about it to others? g. Have formed and/ or is part of a social group just for male 1 2 3 4 nurses at my place of work? k. Women co-workers treat you better than they 1 2 3 4 do other women workers because you are a man? l. Women bosses/supervisors treat you better 1 2 3 4 than they do women workers because you are a man? m. Male co-workers treat you better than they 1 2 3 4 do women workers because you are a man? n. Male bosses/supervisors treat you better than 1 2 3 4 they do women workers because you are a man? i. A patient declined your services because you were a man? 1 2 3 4 j. A patient preferred your services because you were a man? 1 2 3 4

28. Why do you think there are fewer men than women in nursing?

29. What do you think can be done to encourage more men to venture into nursing?

Thank you for taking the time to complete this survey. Your answers are extremely valuable to the success of this study.

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APPENDIX D – Interview Guide for Key informants

Introduction

My name is Walter Thuku a Masters of Arts in Sociology student from the University of Nairobi. I would like to ask you some questions in regards to the performance of male nurses whom you supervise. I hope to use this information to gain an in depth understanding of the role played by male nurses as caregivers. Since you supervise nurses, you may have a greater understanding of the strengths and limitations of male nurses as caregivers.

Healthcare facility ______Position ______Gender ______Education background ______

1. How long have you worked as a supervisor? 2. How would you rate the performance of men as nurses? 3. Do you think women are more suited for nursing as opposed to men? 4. Do you think male nurses have any advantage over female nurses? 5. Do you expect more output from the male nurses? 6. Are male nurses able to cope with the pressure and demands of the job? 7. How satisfied are you with the work done by the male nurses you supervise? 8. Have you ever had a formal complaint from patients, colleagues or doctors made against any of your male nurses? 9. Have any of the male nurses received or been nominated for an award or commendation e.g. employee of the month, nursing excellence award? 10. What kind of feedback do you receive from clients regarding the performance of male nurses? 11. What factor or factors do you think limit the performance of male nurses? 12. What factor or factors do you think enhance the performance of male nurses? 13. Why do you think there are fewer men than women in nursing? 14. What do you think can be done to encourage more men to venture into nursing?

Thank you for your cooperation and volunteering your precious time.

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